MEDICARE: MS. TERESA LYNN LATHAM PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA 14774	CA

General Provider Information

NPI Number	:	1891712881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. TERESA LYNN LATHAM PA-C

Provider Business Mailing Address
First Line	:	18811 HUNTINGTON ST STE 130
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92648-6003
Country	:	US
Telephone Number	:	714-596-1105
Fax Number	:	714-596-1155

Provider Business Practice Location Address
First Line	:	18811 HUNTINGTON ST STE 130
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92648-6003
Country	:	US
Telephone Number	:	714-596-1105
Fax Number	:	714-596-1155

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/16/2006
Last Update Date	:	04/15/2011

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