Provider Demographics
NPI:1255400404
Name:KOEBEL, TERESA A (PA-C)
Entity type:Individual
Prefix:MS
First Name:TERESA
Middle Name:A
Last Name:KOEBEL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 MEDICAL PKWY
Mailing Address - Street 2:STE 101
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3743
Mailing Address - Country:US
Mailing Address - Phone:410-295-8900
Mailing Address - Fax:443-481-6515
Practice Address - Street 1:2000 MEDICAL PKWY
Practice Address - Street 2:STE 101
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3743
Practice Address - Country:US
Practice Address - Phone:410-295-8900
Practice Address - Fax:443-481-6515
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2016-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002041363A00000X
MDC002041363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406438ZDR9Medicare PIN