Provider Demographics
NPI:1174988745
Name:MAZZARESE, ALEXANDRA M
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:M
Last Name:MAZZARESE
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 1:241 S 49TH ST APT 321
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19139-4285
Mailing Address - Country:US
Mailing Address - Phone:908-432-2434
Mailing Address - Fax:
Practice Address - Street 1:90 BRICK RD FL 3
Practice Address - Street 2:
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2177
Practice Address - Country:US
Practice Address - Phone:856-355-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-23
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NJ25MP00440600363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program