Provider Demographics
NPI:1619024494
Name:GRIMES, TERESA G (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:G
Last Name:GRIMES
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:N6480 SHOREWOOD MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:LAKE MILLS
Mailing Address - State:WI
Mailing Address - Zip Code:53551-9730
Mailing Address - Country:US
Mailing Address - Phone:920-648-4380
Mailing Address - Fax:
Practice Address - Street 1:132 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:WI
Practice Address - Zip Code:53098-3304
Practice Address - Country:US
Practice Address - Phone:920-261-2020
Practice Address - Fax:920-261-0457
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI994-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41958600Medicaid
WIP10518Medicare UPIN