Provider Demographics
NPI:1134492432
Name:SALEH, THERESA GOEDERT (PA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:GOEDERT
Last Name:SALEH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARIE
Other - Middle Name:THERESA
Other - Last Name:GOEDERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:3210 SW 33RD RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-7405
Mailing Address - Country:US
Mailing Address - Phone:352-873-7788
Mailing Address - Fax:352-873-9397
Practice Address - Street 1:3210 SW 33RD RD
Practice Address - Street 2:SUITE 101
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34474-7405
Practice Address - Country:US
Practice Address - Phone:352-873-7788
Practice Address - Fax:352-873-9397
Is Sole Proprietor?:No
Enumeration Date:2012-02-16
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9101325363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant