Provider Demographics
NPI:1770205098
Name:GOTTFREDSON, TERESA (PA-C)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:GOTTFREDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:7321 TRIANON CT
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-7334
Mailing Address - Country:US
Mailing Address - Phone:817-403-4100
Mailing Address - Fax:
Practice Address - Street 1:5236 W UNIVERSITY DR PHYSICIAN OFFICE BUILDING I
Practice Address - Street 2:STE 2200
Practice Address - City:MCKINNEY
Practice Address - State:TX
Practice Address - Zip Code:75071
Practice Address - Country:US
Practice Address - Phone:469-800-5325
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA16263363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant