Provider Demographics
NPI:1801000237
Name:THAIS, TERESA M (FNP)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:M
Last Name:THAIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 BAKER STREET
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626
Mailing Address - Country:US
Mailing Address - Phone:714-557-6300
Mailing Address - Fax:714-966-9509
Practice Address - Street 1:722 BAKER STREET
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626
Practice Address - Country:US
Practice Address - Phone:714-557-6300
Practice Address - Fax:714-966-9509
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2016-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA523371163WG0000X
CA16954363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABJ273ZMedicare PIN
CACB219972Medicare PIN