Provider Demographics
NPI:1235166323
Name:BURRELL, TERRY J (CNM, PHD)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:J
Last Name:BURRELL
Suffix:
Gender:M
Credentials:CNM, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-364-3300
Mailing Address - Fax:701-364-8906
Practice Address - Street 1:3000 32ND AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-6132
Practice Address - Country:US
Practice Address - Phone:701-364-8000
Practice Address - Fax:701-364-8078
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR20970367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDHP25721OtherHEALTHPARTNERS #
ND9D421BUOtherMNBS #
NDND200077OtherLHS #
ND12070OtherNDBS #
NDDA9011015515OtherPREFERRED ONE #
ND142324OtherUCARE #
ND19500Medicaid
ND569740900Medicaid
ND0701575OtherMEDICA #
ND0702337OtherMEDICA #
ND900339OtherAMERICA'S PPO/ARAZ #
ND9D420BUOtherMNBS #
ND12070Medicare ID - Type UnspecifiedND MEDICARE #
NDND200077OtherLHS #
NDHP25721OtherHEALTHPARTNERS #