Provider Demographics
NPI:1316300312
Name:TERRY, GEORGE W JR (CSA)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:W
Last Name:TERRY
Suffix:JR
Gender:M
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:934 SIESTA DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40475-3406
Mailing Address - Country:US
Mailing Address - Phone:859-753-5222
Mailing Address - Fax:
Practice Address - Street 1:934 SIESTA DR
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-3406
Practice Address - Country:US
Practice Address - Phone:859-753-5222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2016-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA283246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant