Provider Demographics
NPI:1164025292
Name:MORI, TERYN (PA-C)
Entity Type:Individual
Prefix:
First Name:TERYN
Middle Name:
Last Name:MORI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TERYN
Other - Middle Name:
Other - Last Name:WEIDEMANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:154 COLLEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-1007
Mailing Address - Country:US
Mailing Address - Phone:757-446-7158
Mailing Address - Fax:
Practice Address - Street 1:4740 PEARL PKWY STE 200
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3080
Practice Address - Country:US
Practice Address - Phone:303-449-2730
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0006803363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant