Provider Demographics
NPI:1295007342
Name:MCKINNEY, TERESA BETH (PA-C)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:BETH
Last Name:MCKINNEY
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 315
Mailing Address - Street 2:
Mailing Address - City:CHOUTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74337-0315
Mailing Address - Country:US
Mailing Address - Phone:918-476-6030
Mailing Address - Fax:918-476-6038
Practice Address - Street 1:901 SE PLAZA AVE STE 5
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72712-5473
Practice Address - Country:US
Practice Address - Phone:479-273-3376
Practice Address - Fax:479-273-3468
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2022-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA464363A00000X
OK3046363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200836020AMedicaid