Provider Demographics
NPI:1174804124
Name:HODGENS, ALEXANDER STEPHEN (PA)
Entity type:Individual
Prefix:MR
First Name:ALEXANDER
Middle Name:STEPHEN
Last Name:HODGENS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 NORTH WAY
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1253
Mailing Address - Country:US
Mailing Address - Phone:315-256-3951
Mailing Address - Fax:
Practice Address - Street 1:8901 ROCKVILLE PIKE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20889-2111
Practice Address - Country:US
Practice Address - Phone:315-256-3951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-05
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102206873207R00000X
171000000X, 390200000X
MAPA4789363A00000X
NY363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No171000000XOther Service ProvidersMilitary Health Care Provider
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400115016Medicaid