=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205836038
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERRILL ANDREW VAUGHAN PAC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/22/2005
-----------------------------------------------------
Last Update Date | 09/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5012 US HWY 75 STE 300
-----------------------------------------------------
City | DENISON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75020-4589
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-416-6065
-----------------------------------------------------
Fax | 903-416-6068
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8230 WALNUT HILL LN STE 514
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75231-4407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-345-2929
-----------------------------------------------------
Fax | 214-345-2905
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AS0400X
-----------------------------------------------------
Taxonomy Name | Surgical Physician Assistant
-----------------------------------------------------
License Number | P42740
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------