Basic Information
| Provider Information | |||||||||
| NPI: | 1639437239 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIOTT | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5105 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049155100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192205255 | ||||||||
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| Practice Location | |||||||||
| Address1: | 11550 COMMON OAKS DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276148093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9192205255 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2012 | ||||||||
| LastUpdateDate: | 08/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer | 363A00000X | 0010-11395 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0010-11395 | 01 | NC | MEDICAL LICENSE | OTHER |