Provider Demographics
NPI:1467054783
Name:EDENS, ALEXANDRA TYSON (PT)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:TYSON
Last Name:EDENS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:760 HIGHLAND OAKS DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-7114
Mailing Address - Country:US
Mailing Address - Phone:336-659-8634
Mailing Address - Fax:336-659-8636
Practice Address - Street 1:760 HIGHLAND OAKS DR
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-7114
Practice Address - Country:US
Practice Address - Phone:336-659-8634
Practice Address - Fax:336-659-8636
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC197352251S0007X, 2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic