Provider Demographics
NPI:1629124854
Name:TERRY, KIM C (PA)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:C
Last Name:TERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 WREN ST
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-1529
Mailing Address - Country:US
Mailing Address - Phone:803-259-5762
Mailing Address - Fax:803-259-3250
Practice Address - Street 1:526 NORTH ST
Practice Address - Street 2:
Practice Address - City:BAMBERG
Practice Address - State:SC
Practice Address - Zip Code:29003-1319
Practice Address - Country:US
Practice Address - Phone:803-245-2433
Practice Address - Fax:803-245-6274
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1153363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1096PAMedicaid
SC1153OtherMEDICAL LICENSE
SCAA5333Medicare UPIN