Provider Demographics
NPI:1518423490
Name:TETA, ASHLEY PAIGE (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:PAIGE
Last Name:TETA
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 DUANE ST
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-4201
Mailing Address - Country:US
Mailing Address - Phone:732-407-0252
Mailing Address - Fax:
Practice Address - Street 1:505 GRAND BLVD STE 1
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-5300
Practice Address - Country:US
Practice Address - Phone:631-243-1313
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-15
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY023271207N00000X
023271363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207N00000XAllopathic & Osteopathic PhysiciansDermatology