Provider Demographics
NPI:1740338359
Name:BAUER, TERESE A (MD)
Entity type:Individual
Prefix:
First Name:TERESE
Middle Name:A
Last Name:BAUER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:TERESE
Other - Middle Name:A
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10820 W 64TH ST STE 202
Mailing Address - Street 2:GIANNA FAMILY CARE
Mailing Address - City:SHAWNEE
Mailing Address - State:KS
Mailing Address - Zip Code:66203-3571
Mailing Address - Country:US
Mailing Address - Phone:913-890-2555
Mailing Address - Fax:
Practice Address - Street 1:10820 W 64TH ST STE 202
Practice Address - Street 2:GIANNA FAMILY CARE
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66203-3571
Practice Address - Country:US
Practice Address - Phone:913-890-2555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI47982-020207Q00000X
KS0436612207Q00000X
MO2013026055207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34666700Medicaid