Provider Demographics
NPI:1679288534
Name:MYCOCK, ALEXANDRA NICOLE (PA-C)
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:NICOLE
Last Name:MYCOCK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6130
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-6130
Mailing Address - Country:US
Mailing Address - Phone:864-583-0053
Mailing Address - Fax:864-583-0147
Practice Address - Street 1:279 E KENNEDY ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1912
Practice Address - Country:US
Practice Address - Phone:864-583-0053
Practice Address - Fax:864-583-0390
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
SCPA4805363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant