Provider Demographics
NPI:1194592741
Name:PEGUES, TEA
Entity type:Individual
Prefix:
First Name:TEA
Middle Name:
Last Name:PEGUES
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 1:522 W CASHMERE RD
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-1622
Mailing Address - Country:US
Mailing Address - Phone:720-557-2947
Mailing Address - Fax:
Practice Address - Street 1:1414 E 39TH ST APT 146
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74105-3388
Practice Address - Country:US
Practice Address - Phone:720-557-2947
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-05
Last Update Date:2025-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID58717682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
2000057995OtherBOARD OF CERTIFICATION