Provider Demographics
NPI:1134648520
Name:TERRY, ADRIENNE NATASHA (PA-C)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:NATASHA
Last Name:TERRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ADRIENNE
Other - Middle Name:NATASHA
Other - Last Name:SIRSTINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3725 W 4100 S
Mailing Address - Street 2:
Mailing Address - City:WEST VALLEY CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84120-5530
Mailing Address - Country:US
Mailing Address - Phone:801-965-3600
Mailing Address - Fax:
Practice Address - Street 1:3725 W 4100 S
Practice Address - Street 2:
Practice Address - City:WEST VALLEY
Practice Address - State:UT
Practice Address - Zip Code:84120-5530
Practice Address - Country:US
Practice Address - Phone:801-965-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-17
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10513037-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant