Provider Demographics
NPI:1942671342
Name:PENDERGRASS, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:PENDERGRASS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5394 SUMMER CITY RD
Mailing Address - Street 2:
Mailing Address - City:EVENSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37332-4108
Mailing Address - Country:US
Mailing Address - Phone:269-967-9089
Mailing Address - Fax:
Practice Address - Street 1:136 WHEELERTOWN AVE
Practice Address - Street 2:
Practice Address - City:PIKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37367
Practice Address - Country:US
Practice Address - Phone:423-447-3524
Practice Address - Fax:423-447-3621
Is Sole Proprietor?:No
Enumeration Date:2015-10-12
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2852207Q00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine