Basic Information
| Provider Information | |||||||||
| NPI: | 1609366921 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHARLES | ||||||||
| FirstName: | TEAGAN | ||||||||
| MiddleName: | NICHOLE | ||||||||
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| Credential: | MPAS, PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25723 OLD FREDERICKSBURG RD | ||||||||
| Address2: | |||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 780156605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104509000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 25723 OLD FREDERICKSBURG RD | ||||||||
| Address2: | |||||||||
| City: | BOERNE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104506800 | ||||||||
| FaxNumber: | 2104506801 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2018 | ||||||||
| LastUpdateDate: | 12/10/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA11878 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 385151102 | 01 | TX | CSHCN | OTHER | 385151101 | 05 | TX | MEDICAID |