Provider Demographics
NPI:1508958463
Name:STUCKEY, TERRY L (PA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:STUCKEY
Suffix:
Gender:M
Credentials:PA
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 634280
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-0041
Mailing Address - Country:US
Mailing Address - Phone:517-336-8080
Mailing Address - Fax:517-336-9122
Practice Address - Street 1:1215 E MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-1811
Practice Address - Country:US
Practice Address - Phone:517-364-2223
Practice Address - Fax:517-364-3131
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2012-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI001992363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N50750Medicare ID - Type Unspecified
MIN88100016Medicare PIN
MIC37626052Medicare PIN