Provider Demographics
NPI:1003883943
Name:MCCREADY, THERESA (PA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:MCCREADY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10339 CREATION CT
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34654-3661
Mailing Address - Country:US
Mailing Address - Phone:631-786-9123
Mailing Address - Fax:
Practice Address - Street 1:3231 MCMULLEN BOOTH RD
Practice Address - Street 2:
Practice Address - City:SAFETY HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34695-6607
Practice Address - Country:US
Practice Address - Phone:727-507-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010412-1363A00000X
FL9104660363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
5810L21801Medicare ID - Type Unspecified
Q39806Medicare UPIN