Basic Information
| Provider Information | |||||||||
| NPI: | 1174065817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REEDER | ||||||||
| FirstName: | ALLIX | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BULLOCK | ||||||||
| OtherFirstName: | ALLIX | ||||||||
| OtherMiddleName: | |||||||||
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| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | P.O. BOX 52948 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379502948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8653065708 | ||||||||
| FaxNumber: | 8655847712 | ||||||||
| Practice Location | |||||||||
| Address1: | 9430 PARK WEST BLVD STE 310 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379234203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8656905263 | ||||||||
| FaxNumber: | 8655883740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2016 | ||||||||
| LastUpdateDate: | 07/14/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 3146 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 3146 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 103I973966 | 01 | TN | MEDICARE | OTHER | Q026756 | 05 | TN | MEDICAID |