Provider Demographics
NPI:1104890672
Name:MARTIN, TERESA D (PA-C)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:D
Last Name:MARTIN
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 1:1209 HIGHKNOLL LANE
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78628-1015
Mailing Address - Country:US
Mailing Address - Phone:904-468-0111
Mailing Address - Fax:
Practice Address - Street 1:1855 GATTIS SCHOOL RD
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78664-7428
Practice Address - Country:US
Practice Address - Phone:512-238-6268
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22297363A00000X
NVPA1792363A00000X
MT35362363A00000X
TXPA12432363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXPA12432OtherPA LICENSE
GA173353712AMedicaid
GAS72417Medicare UPIN