Provider Demographics
NPI:1134765423
Name:PAGE, TATEISHA LYNELLE (PA)
Entity type:Individual
Prefix:
First Name:TATEISHA
Middle Name:LYNELLE
Last Name:PAGE
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 1:113 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NC
Mailing Address - Zip Code:28398-1924
Mailing Address - Country:US
Mailing Address - Phone:910-293-7246
Mailing Address - Fax:
Practice Address - Street 1:113 S PINE ST
Practice Address - Street 2:
Practice Address - City:WARSAW
Practice Address - State:NC
Practice Address - Zip Code:28398-1924
Practice Address - Country:US
Practice Address - Phone:910-293-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2019-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-09435363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical