Provider Demographics
NPI:1508142001
Name:GAJEWSKI, TERESA MARIE (PA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:MARIE
Last Name:GAJEWSKI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TERESA
Other - Middle Name:MARIE
Other - Last Name:STAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:124 SIEGLER ST
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54303-2636
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:124 SIEGLER ST
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54303-2636
Practice Address - Country:US
Practice Address - Phone:920-494-9661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-27
Last Update Date:2012-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2859-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant