Provider Demographics
NPI:1154656528
Name:ELLIOTT, TERRY (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TERRY
Middle Name:
Last Name:ELLIOTT
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 1:8631 W 3RD ST STE 945E
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5912
Mailing Address - Country:US
Mailing Address - Phone:310-657-0123
Mailing Address - Fax:310-657-0142
Practice Address - Street 1:8631 W 3RD ST STE 945E
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5912
Practice Address - Country:US
Practice Address - Phone:310-657-0123
Practice Address - Fax:310-657-0142
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-02
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20583363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical