Provider Demographics
NPI:1043580046
Name:PRESTON, TERESA ROSE (PA-C)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:ROSE
Last Name:PRESTON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 HOWARD AVE
Mailing Address - Street 2:SUITE B204
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-4810
Mailing Address - Country:US
Mailing Address - Phone:814-889-6111
Mailing Address - Fax:814-889-6114
Practice Address - Street 1:501 HOWARD AVE
Practice Address - Street 2:SUITE B204
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-4810
Practice Address - Country:US
Practice Address - Phone:814-889-6111
Practice Address - Fax:814-889-6114
Is Sole Proprietor?:No
Enumeration Date:2012-01-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051753363A00000X
PAOA002058363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant