Provider Demographics
NPI:1356703243
Name:TERESA R KROEKER MD PA
Entity type:Organization
Organization Name:TERESA R KROEKER MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:R
Authorized Official - Last Name:KROEKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:512-491-0017
Mailing Address - Street 1:12319 N MOPAC EXPY
Mailing Address - Street 2:260
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-2414
Mailing Address - Country:US
Mailing Address - Phone:512-491-0017
Mailing Address - Fax:512-491-0063
Practice Address - Street 1:12319 N MOPAC EXPY
Practice Address - Street 2:260
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758-2414
Practice Address - Country:US
Practice Address - Phone:512-491-0017
Practice Address - Fax:512-491-0063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-22
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2086S0120X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric SurgeryGroup - Multi-Specialty