Provider Demographics
NPI:1538462619
Name:TEEL, KELLY TANNER (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:TANNER
Last Name:TEEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:TANNER
Other - Last Name:TEEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:506 GRAHAM DR
Mailing Address - Street 2:SUITE 170
Mailing Address - City:TOMBALL
Mailing Address - State:TX
Mailing Address - Zip Code:77375-3346
Mailing Address - Country:US
Mailing Address - Phone:281-259-9943
Mailing Address - Fax:281-259-9142
Practice Address - Street 1:506 GRAHAM DR
Practice Address - Street 2:SUITE 170
Practice Address - City:TOMBALL
Practice Address - State:TX
Practice Address - Zip Code:77375-3346
Practice Address - Country:US
Practice Address - Phone:281-259-9943
Practice Address - Fax:281-259-9142
Is Sole Proprietor?:No
Enumeration Date:2010-12-13
Last Update Date:2015-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363AS0400X
TXPA07013363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX297624301Medicaid
TX297624302Medicaid
TXPA07013OtherTEXAS LICENSE
TX297624301Medicaid
TXTXB159699Medicare PIN