Provider Demographics
NPI:1891712881
Name:LATHAM, TERESA LYNN (PA-C)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:LYNN
Last Name:LATHAM
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:18811 HUNTINGTON ST STE 130
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-6003
Mailing Address - Country:US
Mailing Address - Phone:714-596-1105
Mailing Address - Fax:714-596-1155
Practice Address - Street 1:18811 HUNTINGTON ST STE 130
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92648-6003
Practice Address - Country:US
Practice Address - Phone:714-596-1105
Practice Address - Fax:714-596-1155
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-16
Last Update Date:2011-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 14774363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical