Provider Demographics
NPI:1649430778
Name:BOONE, TERRY W (PAC)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:W
Last Name:BOONE
Suffix:
Gender:
Credentials:PAC
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 347
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:KY
Mailing Address - Zip Code:42078-0347
Mailing Address - Country:US
Mailing Address - Phone:270-988-3298
Mailing Address - Fax:270-988-4642
Practice Address - Street 1:308 S MAIN ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:KY
Practice Address - Zip Code:42064-1545
Practice Address - Country:US
Practice Address - Phone:270-965-4377
Practice Address - Fax:270-965-9569
Is Sole Proprietor?:No
Enumeration Date:2008-06-12
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1128363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100064700Medicaid
KY0627309Medicare PIN
KY7100064700Medicaid
KY0627210Medicare PIN
KY0627408Medicare PIN