Provider Demographics
NPI:1558632778
Name:SCHWARTZ, TERRENCE (PA-C)
Entity Type:Individual
Prefix:
First Name:TERRENCE
Middle Name:
Last Name:SCHWARTZ
Suffix:
Gender:M
Credentials:PA-C
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 266
Mailing Address - Street 2:
Mailing Address - City:GLENNS FERRY
Mailing Address - State:ID
Mailing Address - Zip Code:83623-0266
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:350 MAIN STREET
Practice Address - Street 2:
Practice Address - City:GRAND VIEW
Practice Address - State:ID
Practice Address - Zip Code:83624
Practice Address - Country:US
Practice Address - Phone:120-883-4292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WYTL#541363A00000X
IDPA-1044363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant