Provider Demographics
NPI:1295700425
Name:GREEN, TERESA DESHAWN (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:DESHAWN
Last Name:GREEN
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:MRS
Other - First Name:TERESA
Other - Middle Name:DESHAWN
Other - Last Name:DREW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:TERESA HARGROVE
Mailing Address - Street 1:8422 N 123RD EAST AVE
Mailing Address - Street 2:
Mailing Address - City:OWASSO
Mailing Address - State:OK
Mailing Address - Zip Code:74055-2130
Mailing Address - Country:US
Mailing Address - Phone:918-858-4353
Mailing Address - Fax:668-246-2942
Practice Address - Street 1:8422 N 123RD EAST AVE
Practice Address - Street 2:
Practice Address - City:OWASSO
Practice Address - State:OK
Practice Address - Zip Code:74055-2130
Practice Address - Country:US
Practice Address - Phone:918-293-2140
Practice Address - Fax:918-712-7164
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2023-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA031082363A00000X
MDC0003136363A00000X
DEC5-0000491363AM0700X
OK2962363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q13539Medicare UPIN