Provider Demographics
NPI:1275563819
Name:BLACK, TERRY L (CRNA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:BLACK
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1699 WASHINGTON RD
Mailing Address - Street 2:STE 307
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15228-1629
Mailing Address - Country:US
Mailing Address - Phone:412-831-3744
Mailing Address - Fax:412-831-5663
Practice Address - Street 1:3109 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16602-4475
Practice Address - Country:US
Practice Address - Phone:814-696-8886
Practice Address - Fax:814-696-8883
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN280569L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001300Medicare ID - Type Unspecified
PAR78622Medicare UPIN