Provider Demographics
NPI:1265461479
Name:GRAKLANOFF, TERESA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:
Last Name:GRAKLANOFF
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 1:1618 S. MILLENNIUM WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-6457
Mailing Address - Country:US
Mailing Address - Phone:208-884-3376
Mailing Address - Fax:208-884-0858
Practice Address - Street 1:1618 S. MILLENNIUM WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-6457
Practice Address - Country:US
Practice Address - Phone:208-884-3376
Practice Address - Fax:208-884-0858
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2019-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA393363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID806410600Medicaid
IDP75939Medicare UPIN
ID806410600Medicaid