Provider Demographics
NPI:1063231496
Name:WRIGHT, TEONA (PA)
Entity type:Individual
Prefix:
First Name:TEONA
Middle Name:
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10635 DESOTO RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-4139
Mailing Address - Country:US
Mailing Address - Phone:901-206-1479
Mailing Address - Fax:
Practice Address - Street 1:7111 SOUTHCREST PKWY STE 109
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4852
Practice Address - Country:US
Practice Address - Phone:662-349-9116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-03
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS00834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant