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NPI Code Detail

MEDICARE: COURTNEY L TELLER PA-C

MEDICARE: COURTNEY L TELLER PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant085004426IL

Medicare Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1381220033OTHERILMEDICARE

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
2MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1417208505
Entity Type Code : Individual
Provider Name (Legal Business Name) : COURTNEY L TELLER PA-C
Provider Business Mailing Address
First Line : 102 S HENNEPIN AVE
Second Line :
City : DIXON
State : IL
Zip : 61021-3013
Country : US
Telephone Number : 815-285-8523
Fax Number : 815-285-8901
Provider Business Practice Location Address
First Line : 102 S HENNEPIN AVE
Second Line :
City : DIXON
State : IL
Zip : 61021-3013
Country : US
Telephone Number : 815-285-8523
Fax Number : 815-285-8901
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/28/2012
Last Update Date : 08/27/2018

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Directions to “ COURTNEY L TELLER PA-C” Practice Location

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