Provider Demographics
NPI:1295718278
Name:WU, THERESA M (PA-C)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:M
Last Name:WU
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:M
Other - Last Name:HAVEMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6541 N MONTROSE DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85741-3124
Mailing Address - Country:US
Mailing Address - Phone:602-769-0574
Mailing Address - Fax:
Practice Address - Street 1:627 N SWAN RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85711-2101
Practice Address - Country:US
Practice Address - Phone:520-308-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2020-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2453363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86080015085259A665OtherTRIWEST
AZ970018753OtherRAILROAD MEDICARE
AZ556631Medicaid
AZ64688Medicare ID - Type Unspecified