Provider Demographics
NPI:1942383880
Name:KERN, TERRY (PT)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:KERN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5971 JEFFERSON ST NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-3413
Mailing Address - Country:US
Mailing Address - Phone:505-761-0016
Mailing Address - Fax:505-761-0025
Practice Address - Street 1:5971 JEFFERSON ST NE
Practice Address - Street 2:SUITE 102
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-3413
Practice Address - Country:US
Practice Address - Phone:505-761-0016
Practice Address - Fax:505-761-0025
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM515174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM348231002Medicare ID - Type Unspecified
NM348231002Medicare PIN