Provider Demographics
NPI:1861895807
Name:TANABE, TERESA
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:TANABE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746081
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6081
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:303-996-1600
Practice Address - Street 1:5996 E 64TH AVE
Practice Address - Street 2:
Practice Address - City:COMMERCE CITY
Practice Address - State:CO
Practice Address - Zip Code:80022-3317
Practice Address - Country:US
Practice Address - Phone:720-463-6758
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-05
Last Update Date:2023-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO991480363L00000X
COAPN.0991480-NP363LG0600X, 363LP2300X
CA95000952363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07786751Medicaid
CO07786751Medicaid
CO439519ZMUNMedicare PIN