Provider Demographics
NPI:1174591242
Name:TEACLE, JON C (PAC)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:C
Last Name:TEACLE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 EARL RUDDER FWY S STE 103
Mailing Address - Street 2:
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77845-6099
Mailing Address - Country:US
Mailing Address - Phone:979-731-8888
Mailing Address - Fax:979-731-8848
Practice Address - Street 1:2803 EARL RUDDER FWY S STE 103
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77845-6099
Practice Address - Country:US
Practice Address - Phone:979-731-8888
Practice Address - Fax:979-731-8848
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02372363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX190253801Medicaid
TX8Y2631OtherBCBSTX
TX8Y2631OtherBCBSTX
TX8J8314Medicare PIN
TX190253801Medicaid