Provider Demographics
NPI:1679611792
Name:FORDYCE, TERESA A (PA-C)
Entity type:Individual
Prefix:MRS
First Name:TERESA
Middle Name:A
Last Name:FORDYCE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1901 S CEDAR ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-2308
Mailing Address - Country:US
Mailing Address - Phone:253-572-3520
Mailing Address - Fax:253-627-9842
Practice Address - Street 1:1901 S CEDAR ST
Practice Address - Street 2:SUITE 201
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2308
Practice Address - Country:US
Practice Address - Phone:253-572-3520
Practice Address - Fax:253-627-9842
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2016-01-15
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAPA10002505363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant