Provider Demographics
NPI:1164730487
Name:TEAGUE, KRISTIN KATHLEEN (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:KATHLEEN
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:KATHLEEN
Other - Last Name:LANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:125 QUEENS RD STE 540
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-3215
Practice Address - Country:US
Practice Address - Phone:980-302-6560
Practice Address - Fax:980-302-6565
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001002551363AS0400X
NC0010-02551363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1164730487Medicaid
NC8102004Medicaid
SC1102PAMedicaid
NC1164730487Medicaid