Provider Demographics
NPI:1730110693
Name:MASTIN, TERRYE (APRN,BC)
Entity Type:Individual
Prefix:
First Name:TERRYE
Middle Name:
Last Name:MASTIN
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5625 POPLAR AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-3816
Mailing Address - Country:US
Mailing Address - Phone:901-761-1220
Mailing Address - Fax:901-763-4332
Practice Address - Street 1:5625 POPLAR AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-3816
Practice Address - Country:US
Practice Address - Phone:901-761-1220
Practice Address - Fax:901-763-4332
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN6208207K00000X
TNTN6208364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ46724Medicare UPIN