Provider Demographics
NPI:1164693545
Name:PANGBURN, TERRY L
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:PANGBURN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 S ELM ST
Mailing Address - Street 2:
Mailing Address - City:MOULTON
Mailing Address - State:IA
Mailing Address - Zip Code:52572-1441
Mailing Address - Country:US
Mailing Address - Phone:641-856-7734
Mailing Address - Fax:
Practice Address - Street 1:109 S ELM ST
Practice Address - Street 2:
Practice Address - City:MOULTON
Practice Address - State:IA
Practice Address - Zip Code:52572-1441
Practice Address - Country:US
Practice Address - Phone:641-856-7734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA022AA0001172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver