Provider Demographics
NPI:1245375625
Name:HODGSON, TERESA A (PAC)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:A
Last Name:HODGSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:307 ELIZABETH LN
Mailing Address - Street 2:
Mailing Address - City:MCCOOK
Mailing Address - State:NE
Mailing Address - Zip Code:69001-2228
Mailing Address - Country:US
Mailing Address - Phone:308-345-5696
Mailing Address - Fax:308-334-5144
Practice Address - Street 1:406 E 1ST ST
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:NE
Practice Address - Zip Code:69044-1715
Practice Address - Country:US
Practice Address - Phone:308-334-5155
Practice Address - Fax:308-334-5144
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE720363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE38521OtherBLUE CROSS
NE38521OtherBLUE CROSS
272461HOMedicare ID - Type Unspecified