Provider Demographics
NPI:1932182110
Name:RISKE, TERRANCE A (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRANCE
Middle Name:A
Last Name:RISKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8181 N CORNERSTONE DR
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-8752
Mailing Address - Country:US
Mailing Address - Phone:208-772-0785
Mailing Address - Fax:208-762-2704
Practice Address - Street 1:8181 N CORNERSTONE DR
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-8752
Practice Address - Country:US
Practice Address - Phone:208-772-0785
Practice Address - Fax:208-762-2704
Is Sole Proprietor?:No
Enumeration Date:2005-11-22
Last Update Date:2010-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM6012207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002705900Medicaid
ID1126481Medicare ID - Type Unspecified
ID002705900Medicaid