=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295718278
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THERESA M WU P.A.-C.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/23/2005
-----------------------------------------------------
Last Update Date | 04/10/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 627 N SWAN RD
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85711-2101
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 520-308-8990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6541 N MONTROSE DR
-----------------------------------------------------
City | TUCSON
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85741-3124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 602-769-0574
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 2453
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------