Provider Demographics
NPI:1477858611
Name:GILMORE, TERI SUE (NP)
Entity Type:Individual
Prefix:MRS
First Name:TERI
Middle Name:SUE
Last Name:GILMORE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 E RIVER RD
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85718-6526
Mailing Address - Country:US
Mailing Address - Phone:520-795-7750
Mailing Address - Fax:520-320-2155
Practice Address - Street 1:2450 E RIVER RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85718-6526
Practice Address - Country:US
Practice Address - Phone:520-795-7750
Practice Address - Fax:520-320-2155
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2012-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN131386363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ696765Medicaid
AZ696765Medicaid