Provider Demographics
NPI:1881124220
Name:TERRY, GENEVIEVE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:MARIE
Last Name:TERRY
Suffix:
Gender:F
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 1:150 LORALEE PL
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-3923
Mailing Address - Country:US
Mailing Address - Phone:916-792-7992
Mailing Address - Fax:
Practice Address - Street 1:13855 E 14TH ST
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2611
Practice Address - Country:US
Practice Address - Phone:510-357-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-18
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54403363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant