Provider Demographics
NPI:1215994462
Name:TEAGUE, LINDA DIANE (PA-C)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:DIANE
Last Name:TEAGUE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:DIANE
Other - Last Name:GARSKOF
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:2963 W WHITE MOUNTAIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-6257
Mailing Address - Country:US
Mailing Address - Phone:928-368-0765
Mailing Address - Fax:928-368-4540
Practice Address - Street 1:2963 W WHITE MOUNTAIN BLVD
Practice Address - Street 2:
Practice Address - City:LAKESIDE
Practice Address - State:AZ
Practice Address - Zip Code:85929-6257
Practice Address - Country:US
Practice Address - Phone:928-368-0765
Practice Address - Fax:928-368-4540
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZPA1883363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ194209Medicaid
AZ194209Medicaid
AZ70466Medicare ID - Type Unspecified