Provider Demographics
NPI:1790861706
Name:ANDERSEN, TERESA A (MD)
Entity Type:Individual
Prefix:MS
First Name:TERESA
Middle Name:A
Last Name:ANDERSEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22180 OLYMPIC COLLEGE WAY
Mailing Address - Street 2:SUITE 201
Mailing Address - City:POULSBO
Mailing Address - State:WA
Mailing Address - Zip Code:98370-6664
Mailing Address - Country:US
Mailing Address - Phone:360-394-3500
Mailing Address - Fax:360-394-3501
Practice Address - Street 1:22180 OLYMPIC COLLEGE WAY
Practice Address - Street 2:SUITE 201
Practice Address - City:POULSBO
Practice Address - State:WA
Practice Address - Zip Code:98370-6664
Practice Address - Country:US
Practice Address - Phone:360-394-3500
Practice Address - Fax:360-394-3501
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00039456207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8281024Medicaid
WA080178173OtherRAILROAD MEDICARE
WAG8880231Medicare PIN
WAH42468Medicare UPIN