Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 19735 | NC |
N | 2251S0007X | Physical Therapist - Sports | 19735 | NC |
N | 2251X0800X | Physical Therapist - Orthopedic | 19735 | NC |
NPI | 1467054783 |
---|---|
Provider Name | Alexandra Tyson Edens |
First Address | Winston Salem, NC 27103-7114 |
Second Address | Winston Salem, NC 27103-7114 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 11/11/2020 |
Last Update Date | 11/11/2020 |