Provider Demographics
NPI:1164574646
Name:CAMPBELL, TERESA R (PA-C)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:R
Last Name:CAMPBELL
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 4978
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-4978
Mailing Address - Country:US
Mailing Address - Phone:209-575-4575
Mailing Address - Fax:209-575-4598
Practice Address - Street 1:825 DELBON AVE
Practice Address - Street 2:
Practice Address - City:TURLOCK
Practice Address - State:CA
Practice Address - Zip Code:95382-2016
Practice Address - Country:US
Practice Address - Phone:209-664-2790
Practice Address - Fax:209-664-2797
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2016-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13619363A00000X
CANP7094C363L00000X
CA7094363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13619OtherMEDICAL LICENSE
CAPA13619OtherMEDICAL LICENSE