Healthcare Provider Details

I. General information

NPI: 1851057962
Provider Name (Legal Business Name): ALEXANDER LEE GADDIE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/12/2021
Last Update Date: 11/12/2021
Certification Date: 11/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 PEARL ST
AUBURN KY
42206-5121
US

IV. Provider business mailing address

424 LONGVIEW DR
FRANKLIN KY
42134-1560
US

V. Phone/Fax

Practice location:
  • Phone: 270-542-4111
  • Fax:
Mailing address:
  • Phone: 270-218-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA03965
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: