Provider Demographics
NPI:1114037207
Name:DIDOMENICO, TERESA MARIE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:MARIE
Last Name:DIDOMENICO
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:PO BOX 201
Mailing Address - Street 2:
Mailing Address - City:EBEN JUNCTION
Mailing Address - State:MI
Mailing Address - Zip Code:49825-0201
Mailing Address - Country:US
Mailing Address - Phone:906-439-5775
Mailing Address - Fax:
Practice Address - Street 1:1504 SAND POINT ROAD
Practice Address - Street 2:
Practice Address - City:MUNISING
Practice Address - State:MI
Practice Address - Zip Code:49862-1406
Practice Address - Country:US
Practice Address - Phone:906-387-4220
Practice Address - Fax:906-387-5449
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601002779363A00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5601002779OtherMI STATE MEDICAL LICENSE
MIP29950014Medicare PIN
S39827Medicare UPIN
MI5601002779OtherMI STATE MEDICAL LICENSE