Provider Demographics
NPI:1588879977
Name:MARTIN, TERESA MCKNIGHT (CRNA)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:MCKNIGHT
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 WILDWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27803-1728
Mailing Address - Country:US
Mailing Address - Phone:252-977-9200
Mailing Address - Fax:
Practice Address - Street 1:2460 CURTIS ELLIS DR
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-2298
Practice Address - Country:US
Practice Address - Phone:252-443-8015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC117646367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051727Medicaid
NC8051727Medicaid