Provider Demographics
NPI:1437560299
Name:TERRA, MARY ALYSSA (DO)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ALYSSA
Last Name:TERRA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-6460
Mailing Address - Country:US
Mailing Address - Phone:507-837-4164
Mailing Address - Fax:
Practice Address - Street 1:101 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-6460
Practice Address - Country:US
Practice Address - Phone:507-837-4164
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN59590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program