Provider Demographics
NPI:1013077981
Name:BUNKER, TERRY ALAN (PT)
Entity Type:Individual
Prefix:MR
First Name:TERRY
Middle Name:ALAN
Last Name:BUNKER
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 1:5407 NEW COPELAND RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703
Mailing Address - Country:US
Mailing Address - Phone:903-630-7204
Mailing Address - Fax:903-630-7205
Practice Address - Street 1:5407 NEW COPELAND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703
Practice Address - Country:US
Practice Address - Phone:903-630-7204
Practice Address - Fax:903-630-7205
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-11
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1055705225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX107339702Medicaid
TX84382TOtherBCBS TX
TX107339702Medicaid