Provider Demographics
NPI:1588753057
Name:GULLEY, ALEXANDRA (PA)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:GULLEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-5712
Mailing Address - Country:US
Mailing Address - Phone:210-271-7411
Mailing Address - Fax:210-271-9414
Practice Address - Street 1:2810 DACY LN
Practice Address - Street 2:
Practice Address - City:KYLE
Practice Address - State:TX
Practice Address - Zip Code:78640-6322
Practice Address - Country:US
Practice Address - Phone:512-268-8900
Practice Address - Fax:512-268-2250
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA03159363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX187964501Medicaid
8J2855Medicare PIN
TX187964501Medicaid