Provider Demographics
NPI:1447768718
Name:CHILDS, ALEX WADE (PA-C)
Entity type:Individual
Prefix:
First Name:ALEX
Middle Name:WADE
Last Name:CHILDS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 PINE ST
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-2323
Mailing Address - Country:US
Mailing Address - Phone:435-228-8310
Mailing Address - Fax:
Practice Address - Street 1:475 BRUCE ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3474
Practice Address - Country:US
Practice Address - Phone:530-842-3507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-19
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55294363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant