Provider Demographics
NPI:1700859576
Name:O'DONNELL, TERRY SAPHR (PA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:SAPHR
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:131 NEW LONDON TPKE STE 101
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-2246
Mailing Address - Country:US
Mailing Address - Phone:860-659-8904
Mailing Address - Fax:860-246-5828
Practice Address - Street 1:131 NEW LONDON TPKE STE 101
Practice Address - Street 2:
Practice Address - City:GLASTONBURY
Practice Address - State:CT
Practice Address - Zip Code:06033-2246
Practice Address - Country:US
Practice Address - Phone:860-659-8904
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000644363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P87973Medicare UPIN