Provider Demographics
NPI:1104956028
Name:HARTSOCK, TERRANCE R (PA-C)
Entity type:Individual
Prefix:MR
First Name:TERRANCE
Middle Name:R
Last Name:HARTSOCK
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 1226
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:TN
Mailing Address - Zip Code:37065-1226
Mailing Address - Country:US
Mailing Address - Phone:615-591-2732
Mailing Address - Fax:615-591-2779
Practice Address - Street 1:650 JOEL DR
Practice Address - Street 2:
Practice Address - City:FORT CAMPBELL
Practice Address - State:KY
Practice Address - Zip Code:42223-5318
Practice Address - Country:US
Practice Address - Phone:270-956-0650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2018-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN716363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36669332Medicaid
TNPA716OtherSTATE LICENSE
TN4166977OtherBC/BS TN - CUMBERLAND BACK PAIN CLINIC, P.C.
TN1104956028OtherUNITED HEALTHCARE
TN4166977OtherBC/BS TN - CUMBERLAND BACK PAIN CLINIC, P.C.
P13919Medicare UPIN