Provider Demographics
NPI:1508930082
Name:MORGAN, TERRY LEE (PAC)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:LEE
Last Name:MORGAN
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 OLD COFFEE RD
Mailing Address - Street 2:
Mailing Address - City:WRAY
Mailing Address - State:GA
Mailing Address - Zip Code:31798-3801
Mailing Address - Country:US
Mailing Address - Phone:229-382-9338
Mailing Address - Fax:229-382-4282
Practice Address - Street 1:1111 20TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3689
Practice Address - Country:US
Practice Address - Phone:229-382-9338
Practice Address - Fax:229-382-4282
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2010-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003405363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100000332AMedicaid
GAS94106Medicare UPIN
GA97BBFJTMedicare PIN