Provider Demographics
NPI:1639258072
Name:TERWILLIGER, TONYA M (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TONYA
Middle Name:M
Last Name:TERWILLIGER
Suffix:
Gender:F
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 1:1450 6TH ST SE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33880-4505
Mailing Address - Country:US
Mailing Address - Phone:863-293-2147
Mailing Address - Fax:863-294-2767
Practice Address - Street 1:26540 ACE AVE
Practice Address - Street 2:SUITE 107, UNIT D
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-8279
Practice Address - Country:US
Practice Address - Phone:352-530-2306
Practice Address - Fax:352-533-4391
Is Sole Proprietor?:No
Enumeration Date:2006-11-05
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9104043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP01198596OtherRR MEDICARE ID#
FL0038ZOtherBCBS GROUP
FLAA961VMedicare PIN
FLC0192BMedicare PIN
Q75690Medicare UPIN
FLDS2914OtherPROV AND GROUP #