Provider Demographics
NPI:1093388605
Name:BACON, ALEX (APRN)
Entity Type:Individual
Prefix:
First Name:ALEX
Middle Name:
Last Name:BACON
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 FORT SUMMIT WAY
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37915-2146
Mailing Address - Country:US
Mailing Address - Phone:865-374-0555
Mailing Address - Fax:
Practice Address - Street 1:550 FORT SUMMIT WAY
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37915-2146
Practice Address - Country:US
Practice Address - Phone:865-374-0555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-21
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN29956363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health