Healthcare Provider Details

I. General information

NPI: 1275563819
Provider Name (Legal Business Name): TERRY L BLACK CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 12/05/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3109 FAIRWAY DR
ALTOONA PA
16602-4475
US

IV. Provider business mailing address

1699 WASHINGTON RD STE 307
PITTSBURGH PA
15228-1629
US

V. Phone/Fax

Practice location:
  • Phone: 814-696-8886
  • Fax: 814-696-8883
Mailing address:
  • Phone: 412-831-3744
  • Fax: 412-831-5663

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN280569L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: