Individual
MRS. TERESA YVONNE THACKER
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
108 HOUSTON ST, LEXINGTON, VA 24450-2455
(540) 463-7628
Mailing address
213 S JEFFERSON ST STE 1006, ROANOKE, VA 24011-1713
(540) 224-5352
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
0101047078
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
001721893
BCBS
WV
05
—
0053757000
—
WV
01
—
080174378
TRAVLERS MEDICARE
WV
Enumeration date
10/17/2006
Last updated
08/06/2024
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