Provider Demographics
NPI:1356651558
Name:MUSGRAVE, THERESA LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:LYNN
Last Name:MUSGRAVE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:333 N SUMMIT ST FL 7
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1531
Mailing Address - Country:US
Mailing Address - Phone:419-578-7200
Mailing Address - Fax:419-537-5600
Practice Address - Street 1:2865 N REYNOLDS RD BLDG A
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-2100
Practice Address - Country:US
Practice Address - Phone:419-578-7200
Practice Address - Fax:419-537-5600
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003101363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHWAPA36921Medicare PIN