Provider Demographics
NPI:1306462486
Name:GERVELIS, ALEXANDRIA
Entity type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:
Last Name:GERVELIS
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 1:6 BLACKSTONE VALLEY PL STE 306B
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:RI
Mailing Address - Zip Code:02865-1112
Mailing Address - Country:US
Mailing Address - Phone:401-334-4021
Mailing Address - Fax:
Practice Address - Street 1:6 BLACKSTONE VALLEY PL STE 306B
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:RI
Practice Address - Zip Code:02865-1112
Practice Address - Country:US
Practice Address - Phone:401-334-4021
Practice Address - Fax:401-334-4886
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2023-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
RIPA01256363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIPA01256OtherSTATE LICENSE
MAPA7648OtherSTATE LICENSE