Provider Demographics
NPI:1902813736
Name:TEGGER, MARY K (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:TEGGER
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 1:619 NW 6TH AVE FL 5
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3964
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:619 NW 6TH AVE FL 3
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209-3964
Practice Address - Country:US
Practice Address - Phone:503-988-5020
Practice Address - Fax:503-988-5022
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR152807363AM0700X
WAPA10004231363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR022959Medicaid
OR152807OtherOREGON PA LICENSE
WA0155782OtherL&I PIN
OR152807OtherOREGON PA LICENSE
2217594OtherDEA
OR152807OtherOREGON PA LICENSE
WAAB25537Medicare PIN