Provider Demographics
NPI:1073935417
Name:BLOMBERG, TERRI (PA)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:BLOMBERG
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:TERRI
Other - Middle Name:
Other - Last Name:STACY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4320 BRAMBLETON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24018-3405
Mailing Address - Country:US
Mailing Address - Phone:540-725-7546
Mailing Address - Fax:540-725-9741
Practice Address - Street 1:4320 BRAMBLETON AVE STE B
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24018-3405
Practice Address - Country:US
Practice Address - Phone:540-725-7546
Practice Address - Fax:540-725-9741
Is Sole Proprietor?:No
Enumeration Date:2014-01-18
Last Update Date:2015-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110004465363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant