Provider Demographics
NPI:1346069879
Name:TEETER, EMILY GRACE (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:GRACE
Last Name:TEETER
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 1:4 BROOM SHOP LN APT 102
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2240
Mailing Address - Country:US
Mailing Address - Phone:518-813-7517
Mailing Address - Fax:
Practice Address - Street 1:123 EVERETT RD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1407
Practice Address - Country:US
Practice Address - Phone:518-701-2085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-10
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032755363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant