Provider Demographics
NPI:1215923776
Name:BLINT, TERRA M (PA)
Entity type:Individual
Prefix:MS
First Name:TERRA
Middle Name:M
Last Name:BLINT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:901 MCCLINTOCK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BURR RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60527-0872
Mailing Address - Country:US
Mailing Address - Phone:888-220-6432
Mailing Address - Fax:630-654-4253
Practice Address - Street 1:901 MCCLINTOCK DR
Practice Address - Street 2:SUITE 202
Practice Address - City:BURR RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60527-0872
Practice Address - Country:US
Practice Address - Phone:888-220-6432
Practice Address - Fax:630-654-4253
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL085-001698363AM0700X
IA001380363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP43163Medicare UPIN
IAI 10619Medicare PIN
ILK45600Medicare PIN
ILK45599Medicare PIN
ILK45598Medicare PIN