Provider Demographics
NPI:1598856726
Name:BULLARD, TERRY LEE (PAC)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:LEE
Last Name:BULLARD
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 1:6814 LA PRESA DR
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91775-1110
Mailing Address - Country:US
Mailing Address - Phone:626-286-0179
Mailing Address - Fax:
Practice Address - Street 1:403 W F ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764
Practice Address - Country:US
Practice Address - Phone:909-988-3288
Practice Address - Fax:909-988-6767
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2024-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11783363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical