Provider Demographics
NPI:1831879287
Name:TEDROW, THERESE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:THERESE
Middle Name:MARIE
Last Name:TEDROW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 CONCORD PL
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92069-1188
Mailing Address - Country:US
Mailing Address - Phone:760-826-9961
Mailing Address - Fax:
Practice Address - Street 1:332 SANTA FE DR STE 110
Practice Address - Street 2:
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-5143
Practice Address - Country:US
Practice Address - Phone:760-943-6700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-20
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA62976363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant