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General NPI Number Information
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NPI Number | 1710014477
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Entity Type | Individual
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Provider Name | TERRY LEE GOURLEY PA
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Gender | Male
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Dates
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Enumeration Date | 02/28/2007
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Last Update Date | 05/03/2018
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Provider Practice Location Address
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Address Line | 2900 DOOLITTLE DR
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City | ELLSWORTH AFB
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State | SD
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Zip | 57706-4821
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Country | US
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Telephone | 53-853-2736
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Fax | 308-367-4164
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Provider Business Mailing Address
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Address Line | 2900 DOOLITTLE DR
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City | ELLSWORTH AFB
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State | SD
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Zip | 57706-4821
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Country | US
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Telephone | 605-385-3111
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Fax | 605-385-3680
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 866
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License Number State | NE
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