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General NPI Number Information
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NPI Number | 1619969243
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Entity Type | Individual
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Provider Name | TROY TEAGARDIN PAC
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Gender | Male
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Dates
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Enumeration Date | 08/19/2005
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Last Update Date | 10/15/2012
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Provider Practice Location Address
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Address Line | 2500 NILES RD STE 6
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City | SAINT JOSEPH
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State | MI
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Zip | 49085-3268
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Country | US
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Telephone | 269-408-1660
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Fax | 269-408-1665
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Provider Business Mailing Address
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Address Line | 2500 NILES RD STE 6
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City | SAINT JOSEPH
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State | MI
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Zip | 49085-3268
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Country | US
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Telephone | 269-408-1660
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Fax | 269-408-1665
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 5601004173
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License Number State | MI
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