Provider Demographics
NPI:1881671113
Name:POOLER, TERESA K (PA-C)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:K
Last Name:POOLER
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 1:4811 E GRANT RD STE 261
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85712-2776
Mailing Address - Country:US
Mailing Address - Phone:520-202-0490
Mailing Address - Fax:
Practice Address - Street 1:5670 N PROFESSIONAL PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-7878
Practice Address - Country:US
Practice Address - Phone:520-618-1010
Practice Address - Fax:520-784-7040
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ6679363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN093478000Medicaid
MN093478000Medicaid
MN970001791Medicare ID - Type Unspecified