Provider Demographics
NPI:1528563384
Name:WILSON, ALEXANDRA GRACE (DO)
Entity type:Individual
Prefix:DR
First Name:ALEXANDRA
Middle Name:GRACE
Last Name:WILSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:DR
Other - First Name:LEXI
Other - Middle Name:GRACE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2911 CHANTICLEER AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1815
Practice Address - Country:US
Practice Address - Phone:831-477-2350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-26
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A22508208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery