Provider Demographics
NPI:1689644098
Name:HENRIE, TERRY W (PA-C)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:W
Last Name:HENRIE
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 1:503 W PINE ST
Mailing Address - Street 2:PO BOX 550
Mailing Address - City:PHILIP
Mailing Address - State:SD
Mailing Address - Zip Code:57567-3300
Mailing Address - Country:US
Mailing Address - Phone:605-859-2566
Mailing Address - Fax:605-859-2948
Practice Address - Street 1:503 W PINE ST
Practice Address - Street 2:
Practice Address - City:PHILIP
Practice Address - State:SD
Practice Address - Zip Code:57567-3300
Practice Address - Country:US
Practice Address - Phone:605-859-2566
Practice Address - Fax:605-859-2948
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0581207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6827660Medicaid
SDQ27910Medicare UPIN
SD100020Medicare PIN