Healthcare Provider Details

I. General information

NPI: 1578889127
Provider Name (Legal Business Name): TERRY MIZE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIVERSITY OF NEW MEXICO MSC09 5040
ALBUQUERQUE NM
87131-1000
US

IV. Provider business mailing address

335 TULANE PL NE
ALBUQUERQUE NM
87106-2153
US

V. Phone/Fax

Practice location:
  • Phone: 505-925-0857
  • Fax:
Mailing address:
  • Phone: 770-364-1163
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number005610
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2013-0012
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: