Healthcare Provider Details

I. General information

NPI: 1992172969
Provider Name (Legal Business Name): KRISTA L TERESAK PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2015
Last Update Date: 02/28/2024
Certification Date: 02/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 S MAPLE AVE
RIDGEWOOD NJ
07450-4561
US

IV. Provider business mailing address

85 S MAPLE AVE
RIDGEWOOD NJ
07450-4561
US

V. Phone/Fax

Practice location:
  • Phone: 201-445-2830
  • Fax: 201-445-7471
Mailing address:
  • Phone: 201-445-2830
  • Fax: 201-445-7471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number022033
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number25MP00371500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: