Healthcare Provider Details

I. General information

NPI: 1639437239
Provider Name (Legal Business Name): TERESA ELIZABETH ELLIOTT PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2012
Last Update Date: 08/06/2021
Certification Date: 08/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11550 COMMON OAKS DR STE 100
RALEIGH NC
27614-8093
US

IV. Provider business mailing address

PO BOX 5105
BELFAST ME
04915-5100
US

V. Phone/Fax

Practice location:
  • Phone: 919-220-5255
  • Fax:
Mailing address:
  • Phone: 919-220-5255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-11395
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: