Provider Demographics
NPI:1720113376
Name:QUEEN, JULIE BARR TEDDER (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:BARR TEDDER
Last Name:QUEEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:BARR
Other - Last Name:TEDDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 HEALTH PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-4679
Mailing Address - Country:US
Mailing Address - Phone:919-773-1223
Mailing Address - Fax:919-773-1955
Practice Address - Street 1:200 HEALTH PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:GARNER
Practice Address - State:NC
Practice Address - Zip Code:27529-4679
Practice Address - Country:US
Practice Address - Phone:919-773-1223
Practice Address - Fax:919-773-1955
Is Sole Proprietor?:No
Enumeration Date:2007-02-23
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00820363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902803Medicaid
NC2339535Medicare PIN