Healthcare Provider Details

I. General information

NPI: 1376510222
Provider Name (Legal Business Name): TERRY LEE PUCKETT M.D., M.P.H.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24530 FALCON PLACE BLVD STE 100
ABINGDON VA
24211-7665
US

IV. Provider business mailing address

603 CAMPUS DR SUITE 100
ABINGDON VA
24210-9700
US

V. Phone/Fax

Practice location:
  • Phone: 276-619-0075
  • Fax: 276-619-0077
Mailing address:
  • Phone: 276-739-8010
  • Fax: 276-628-1410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberMD 18289
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2083X0100X
TaxonomyOccupational Medicine Physician
License NumberMD 18289
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number0101241208
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: