Provider Demographics
NPI:1073388930
Name:COTTER, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:COTTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11010 POPLAR DR
Mailing Address - Street 2:
Mailing Address - City:LUSBY
Mailing Address - State:MD
Mailing Address - Zip Code:20657-2435
Mailing Address - Country:US
Mailing Address - Phone:407-968-7719
Mailing Address - Fax:
Practice Address - Street 1:6221 METROPOLITAN ST STE 201
Practice Address - Street 2:
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92009-3096
Practice Address - Country:US
Practice Address - Phone:760-753-7127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-21
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical