Basic Information
| Provider Information | |||||||||
| NPI: | 1548737331 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUDD | ||||||||
| FirstName: | ALEXANDRA | ||||||||
| MiddleName: | ROSE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 ACCELERATOR WAY | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379203078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655462663 | ||||||||
| FaxNumber: | 8655469047 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 ACCELERATOR WAY | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379203078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655462663 | ||||||||
| FaxNumber: | 8655469047 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/30/2018 | ||||||||
| LastUpdateDate: | 08/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA2416 | KY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 4685 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 4685 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 7100612140 | 05 | KY | MEDICAID |