Provider Demographics
NPI:1558013615
Name:TERRY, TYRENSON GORDON
Entity Type:Individual
Prefix:
First Name:TYRENSON
Middle Name:GORDON
Last Name:TERRY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:570 NEWCOMB ST SE APT 3
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20032-2552
Mailing Address - Country:US
Mailing Address - Phone:240-535-4166
Mailing Address - Fax:
Practice Address - Street 1:570 NEWCOMB ST SE APT 3
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-2552
Practice Address - Country:US
Practice Address - Phone:240-535-4166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-20
Last Update Date:2022-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant