Provider Demographics
NPI:1013977636
Name:TEASLEY, MYRA LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRA
Middle Name:LYNN
Last Name:TEASLEY
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 1:7628 RAINWATER RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27615-3745
Mailing Address - Country:US
Mailing Address - Phone:919-781-5510
Mailing Address - Fax:919-781-5053
Practice Address - Street 1:4414 LAKE BOONE TRL
Practice Address - Street 2:SUITE 300
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7513
Practice Address - Country:US
Practice Address - Phone:919-781-5510
Practice Address - Fax:919-781-5053
Is Sole Proprietor?:No
Enumeration Date:2006-03-27
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC32181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC32716OtherPARTNERS
NC750598OtherUNITED HEALTHCARE
NC8982346Medicaid
NC82346OtherBC/BS
NC32716OtherPARTNERS
NC750598OtherUNITED HEALTHCARE