Healthcare Provider Details

I. General information

NPI: 1992756233
Provider Name (Legal Business Name): TERRY L SPOHR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

229 S. 7TH STREET
ST. MARIES ID
83861
US

IV. Provider business mailing address

229 S. 7TH STREET
ST. MARIES ID
83861
US

V. Phone/Fax

Practice location:
  • Phone: 208-245-2591
  • Fax: 208-245-5246
Mailing address:
  • Phone: 208-245-2591
  • Fax: 208-245-5246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA28
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: