Provider Demographics
NPI:1598989147
Name:TEAGUE, MARY F (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:F
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1235 OSOS ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-3600
Mailing Address - Country:US
Mailing Address - Phone:805-549-0888
Mailing Address - Fax:805-549-8463
Practice Address - Street 1:1235 OSOS ST
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3600
Practice Address - Country:US
Practice Address - Phone:805-549-0888
Practice Address - Fax:805-549-8463
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16824363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16824OtherPHYSICIANS ASSISTANT