Provider Demographics
NPI:1063506152
Name:TERRELL, THOMAS J (CRNA)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:J
Last Name:TERRELL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 240
Mailing Address - Street 2:
Mailing Address - City:PIPESTEM
Mailing Address - State:WV
Mailing Address - Zip Code:25979-0240
Mailing Address - Country:US
Mailing Address - Phone:304-327-2900
Mailing Address - Fax:304-327-2989
Practice Address - Street 1:1333 SOUTHVIEW DR
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:WV
Practice Address - Zip Code:24701-4317
Practice Address - Country:US
Practice Address - Phone:304-327-2900
Practice Address - Fax:304-327-2989
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV27873367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0066055000Medicaid
WVW43557Medicare UPIN
WV7306871Medicare ID - Type Unspecified