Healthcare Provider Details

I. General information

NPI: 1659806255
Provider Name (Legal Business Name): PATRICK TERRY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2017
Last Update Date: 10/19/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 S OSTEOPATHY AVE
KIRKSVILLE MO
63501-6401
US

IV. Provider business mailing address

3 NEENAH CTR
NEENAH WI
54956-3070
US

V. Phone/Fax

Practice location:
  • Phone: 660-785-1000
  • Fax: 419-502-2821
Mailing address:
  • Phone: 920-237-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2020035162
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number76086
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: