Provider Demographics
NPI:1821071408
Name:TERRY, SAMANTHA (PA)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:TERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2195 HARRODSBURG RD
Mailing Address - Street 2:STE 125
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40504-3504
Mailing Address - Country:US
Mailing Address - Phone:859-323-6711
Mailing Address - Fax:
Practice Address - Street 1:2195 HARRODSBURG RD
Practice Address - Street 2:STE 125
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3504
Practice Address - Country:US
Practice Address - Phone:859-323-6711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2017-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA726363AS0400X, 363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95005047Medicaid
KY95005047Medicaid
P65119Medicare UPIN