Provider Demographics
NPI:1942475918
Name:GEORGE, TERESA L (PA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:L
Last Name:GEORGE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2441 GREAR ST NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-2749
Mailing Address - Country:US
Mailing Address - Phone:503-588-0469
Mailing Address - Fax:503-566-2063
Practice Address - Street 1:2441 GREAR ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2749
Practice Address - Country:US
Practice Address - Phone:503-588-0469
Practice Address - Fax:503-566-2063
Is Sole Proprietor?:No
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA00925363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant