Provider Demographics
NPI:1255303624
Name:WOLF, TERESA LYNN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:LYNN
Last Name:WOLF
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 1:104 ADAIR DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-4516
Mailing Address - Country:US
Mailing Address - Phone:919-648-4435
Mailing Address - Fax:910-267-8932
Practice Address - Street 1:104 ADAIR DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27530-4516
Practice Address - Country:US
Practice Address - Phone:919-648-4435
Practice Address - Fax:910-267-8932
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103636363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP80659Medicare UPIN
NC2758241BMedicare ID - Type Unspecified