Provider Demographics
NPI:1255370318
Name:SCHWARTZ, TERRY LEE (PA-C)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:LEE
Last Name:SCHWARTZ
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:PO BOX 9000
Mailing Address - Street 2:3676 PARKER BLVD
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81008
Mailing Address - Country:US
Mailing Address - Phone:719-553-2200
Mailing Address - Fax:719-553-2216
Practice Address - Street 1:3676 PARKER BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81008
Practice Address - Country:US
Practice Address - Phone:719-553-2200
Practice Address - Fax:719-553-2216
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1225363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1225OtherSTATE LICENSE NUMBER
CO82736863Medicaid
COMS0496910OtherDEA
COC350778Medicare ID - Type Unspecified
COMS0496910OtherDEA