Provider Demographics
NPI:1689689242
Name:UTT, TERRILL R (MD)
Entity Type:Individual
Prefix:
First Name:TERRILL
Middle Name:R
Last Name:UTT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11025 CANYON RD E
Mailing Address - Street 2:STE C
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98373-4264
Mailing Address - Country:US
Mailing Address - Phone:253-536-1020
Mailing Address - Fax:253-536-1612
Practice Address - Street 1:11025 CANYON RD E
Practice Address - Street 2:STE C
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98373-4264
Practice Address - Country:US
Practice Address - Phone:253-536-1020
Practice Address - Fax:253-536-1612
Is Sole Proprietor?:No
Enumeration Date:2006-07-30
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00023440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0202275OtherL & I
WA1111319Medicaid
WAP00280536OtherRAILROAD
WA8937932OtherCRIME VICTIMS
WAG8856576Medicare PIN
WA1111319Medicaid
WAA08697Medicare UPIN