Provider Demographics
NPI:1952510919
Name:EMBAUGH, TERRY LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:LEE
Last Name:EMBAUGH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 E BOULDER ST
Mailing Address - Street 2:SUITE 700
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80909-5533
Mailing Address - Country:US
Mailing Address - Phone:719-365-7172
Mailing Address - Fax:719-444-3759
Practice Address - Street 1:1400 E BOULDER ST
Practice Address - Street 2:SUITE 700
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80909-5533
Practice Address - Country:US
Practice Address - Phone:719-365-7172
Practice Address - Fax:719-444-3759
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2016-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0001838363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO61030325Medicaid
COCOA109683Medicare PIN
CO61030325Medicaid
COC531388Medicare PIN