Provider Demographics
NPI:1669138764
Name:SPRAGUE, ALEXA ANN KIMKER (PA)
Entity type:Individual
Prefix:
First Name:ALEXA
Middle Name:ANN KIMKER
Last Name:SPRAGUE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ALEXA
Other - Middle Name:ANN
Other - Last Name:KIMKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9325 JW CLAY BLVD
Practice Address - Street 2:STE 221
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-5411
Practice Address - Country:US
Practice Address - Phone:704-863-9050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-12
Last Update Date:2025-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11687363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant