Provider Demographics
NPI:1326188269
Name:TEAGUE, AMY KATHRYN (PA)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:KATHRYN
Last Name:TEAGUE
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 1:9600 PATTERSON AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-6053
Mailing Address - Country:US
Mailing Address - Phone:804-217-9601
Mailing Address - Fax:804-217-9602
Practice Address - Street 1:9602 PATTERSON AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-6015
Practice Address - Country:US
Practice Address - Phone:804-217-9601
Practice Address - Fax:804-217-9602
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110840841363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC06695OtherGROUP PTAN
VAC06778OtherMEDICARE PTAN
VAC06778OtherGROUP PTAN
VAQ25213Medicare UPIN