Healthcare Provider Details

I. General information

NPI: 1639136997
Provider Name (Legal Business Name): TERRI GURROLA JORDAN PA-C, MPAS, APA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TERRI LYNN GURROLA PA-C, MPAS, APA

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 05/15/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CENTER ST SUITE 102
COLUMBUS GA
31901
US

IV. Provider business mailing address

7901 VETERANS PKWY
COLUMBUS GA
31909-1723
US

V. Phone/Fax

Practice location:
  • Phone: 706-571-1011
  • Fax: 706-320-8646
Mailing address:
  • Phone: 706-321-1223
  • Fax: 706-321-0819

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number003981
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: