Provider Demographics
NPI:1154383073
Name:TEAGUE, KRISTIN A (PA-C, LAT, ATC)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:A
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:PA-C, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2176 BURKE MEADOWS RD
Mailing Address - Street 2:APT. 205
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6889
Mailing Address - Country:US
Mailing Address - Phone:828-485-8020
Mailing Address - Fax:
Practice Address - Street 1:5905 W NC 10 HWY
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-9732
Practice Address - Country:US
Practice Address - Phone:828-485-8020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2021-01-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC02672255A2300X
NC0010-02693363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2762598Medicare PIN