Provider Demographics
NPI:1831138577
Name:TERRY, ROBERT E (CRNA)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:E
Last Name:TERRY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14700 28TH AVE N
Mailing Address - Street 2:SUITE 20
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55447-4835
Mailing Address - Country:US
Mailing Address - Phone:763-559-3779
Mailing Address - Fax:763-450-3986
Practice Address - Street 1:1420 LONDON RD
Practice Address - Street 2:SUITE 100
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2433
Practice Address - Country:US
Practice Address - Phone:218-728-8508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2009-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR107882-4367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN849343000Medicaid
MN430004048Medicare ID - Type Unspecified