Provider Demographics
NPI:1659335974
Name:AGAN, TERRI J (NPC)
Entity Type:Individual
Prefix:MRS
First Name:TERRI
Middle Name:J
Last Name:AGAN
Suffix:
Gender:F
Credentials:NPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 W TIPTON ST
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:IN
Mailing Address - Zip Code:47274-2363
Mailing Address - Country:US
Mailing Address - Phone:812-523-5862
Mailing Address - Fax:812-523-4753
Practice Address - Street 1:411 W TIPTON ST
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:IN
Practice Address - Zip Code:47274-2363
Practice Address - Country:US
Practice Address - Phone:812-523-5862
Practice Address - Fax:812-523-4753
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000250A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
S51153Medicare UPIN
IN3860606Medicare ID - Type Unspecified