Provider Demographics
NPI:1962106385
Name:RACE, ALDAN WORTHY JAMES I
Entity type:Individual
Prefix:
First Name:ALDAN
Middle Name:WORTHY JAMES
Last Name:RACE
Suffix:I
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 PINTO CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37042-3422
Mailing Address - Country:US
Mailing Address - Phone:518-653-8695
Mailing Address - Fax:
Practice Address - Street 1:5979 DESERT STORM AVE
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5514
Practice Address - Country:US
Practice Address - Phone:270-798-4677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TNPA0000005609363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program