Healthcare Provider Details

I. General information

NPI: 1679032908
Provider Name (Legal Business Name): TERESA CARGILL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERESA TOMASZEWSKI

II. Dates (important events)

Enumeration Date: 03/16/2019
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4290 COPPER RIDGE DR STE 200
TRAVERSE CITY MI
49684-7205
US

IV. Provider business mailing address

4290 COPPER RIDGE DR STE 200
TRAVERSE CITY MI
49684-7205
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-8930
  • Fax: 231-935-8811
Mailing address:
  • Phone: 231-935-8930
  • Fax: 231-935-8811

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601013311
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: