Provider Demographics
NPI:1013252642
Name:BOOKOUT, TERRA LYNN (MS, PA-C)
Entity Type:Individual
Prefix:
First Name:TERRA
Middle Name:LYNN
Last Name:BOOKOUT
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2416 BLACK DUCK AVE.
Mailing Address - Street 2:
Mailing Address - City:JOHNSTOWN
Mailing Address - State:CO
Mailing Address - Zip Code:80534
Mailing Address - Country:US
Mailing Address - Phone:970-231-5441
Mailing Address - Fax:
Practice Address - Street 1:125 INVERNESS DR E
Practice Address - Street 2:SUITE 240
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112-5137
Practice Address - Country:US
Practice Address - Phone:720-863-1004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-08
Last Update Date:2012-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3458363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant