Provider Demographics
NPI:1124204896
Name:CUSTER, TERENIA A (PA-C)
Entity Type:Individual
Prefix:
First Name:TERENIA
Middle Name:A
Last Name:CUSTER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14460 LAKESIDE CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-1345
Mailing Address - Country:US
Mailing Address - Phone:586-685-3285
Mailing Address - Fax:586-685-3286
Practice Address - Street 1:14460 LAKESIDE CIR STE 100
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-1345
Practice Address - Country:US
Practice Address - Phone:586-685-3285
Practice Address - Fax:586-685-3286
Is Sole Proprietor?:No
Enumeration Date:2008-01-12
Last Update Date:2019-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601005174363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant