Healthcare Provider Details

I. General information

NPI: 1609366921
Provider Name (Legal Business Name): TEAGAN NICHOLE CHARLES MPAS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2018
Last Update Date: 12/10/2021
Certification Date: 12/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25723 OLD FREDERICKSBURG RD
BOERNE TX
78015
US

IV. Provider business mailing address

25723 OLD FREDERICKSBURG RD
BOERNE TX
78015-6605
US

V. Phone/Fax

Practice location:
  • Phone: 210-450-6800
  • Fax: 210-450-6801
Mailing address:
  • Phone: 210-450-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11878
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: