Provider Demographics
NPI:1528391539
Name:GANDER, TERRY A (PA)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:A
Last Name:GANDER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N4993 6TH DR
Mailing Address - Street 2:
Mailing Address - City:WESTFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53964-8200
Mailing Address - Country:US
Mailing Address - Phone:608-296-2121
Mailing Address - Fax:
Practice Address - Street 1:N4993 6TH DR
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:WI
Practice Address - Zip Code:53964-8200
Practice Address - Country:US
Practice Address - Phone:608-296-2121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-09
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2500-23363A00000X
IL085-004565363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085-004565OtherSTATE LICENSE
WI2500-23OtherWI LICENSE