Healthcare Provider Details

I. General information

NPI: 1164574646
Provider Name (Legal Business Name): TERESA R CAMPBELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 05/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 DELBON AVE
TURLOCK CA
95382-2016
US

IV. Provider business mailing address

PO BOX 4978
MODESTO CA
95352-4978
US

V. Phone/Fax

Practice location:
  • Phone: 209-664-2790
  • Fax: 209-664-2797
Mailing address:
  • Phone: 209-575-4575
  • Fax: 209-575-4598

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13619
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP7094C
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number7094
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: