Basic Information
| Provider Information | |||||||||
| NPI: | 1285181289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECKER | ||||||||
| FirstName: | AUDREY | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3024 BUSINESS PARK CIR | ||||||||
| Address2: | |||||||||
| City: | GOODLETTSVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370723132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158516033 | ||||||||
| FaxNumber: | 6158512018 | ||||||||
| Practice Location | |||||||||
| Address1: | 1649 WESTGATE CIR | ||||||||
| Address2: | #100 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370278574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158437546 | ||||||||
| FaxNumber: | 6157773376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2016 | ||||||||
| LastUpdateDate: | 05/10/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 6089376 | 01 | TN | BCBS TN | OTHER | Q025828 | 05 | TN | MEDICAID |