Provider Demographics
NPI:1104787639
Name:BEVACQUA, ALEXANDRA KARIN
Entity type:Individual
Prefix:MRS
First Name:ALEXANDRA
Middle Name:KARIN
Last Name:BEVACQUA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 ROBINSON PL
Mailing Address - Street 2:
Mailing Address - City:SHREWSBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:07702-4437
Mailing Address - Country:US
Mailing Address - Phone:732-865-6314
Mailing Address - Fax:
Practice Address - Street 1:1959 RTE 34 STE 202
Practice Address - Street 2:
Practice Address - City:WALL TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:07719-9790
Practice Address - Country:US
Practice Address - Phone:732-943-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-11-24
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15041900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily