Provider Demographics
NPI:1699719534
Name:DURHAM, TERRY D (CRNA)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:D
Last Name:DURHAM
Suffix:
Gender:M
Credentials:CRNA
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 386
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:KY
Mailing Address - Zip Code:42064-0386
Mailing Address - Country:US
Mailing Address - Phone:270-965-5281
Mailing Address - Fax:270-965-4852
Practice Address - Street 1:520 W GUM ST
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:KY
Practice Address - Zip Code:42064-1516
Practice Address - Country:US
Practice Address - Phone:270-965-5281
Practice Address - Fax:270-965-4852
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1069081367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000066369OtherANTHEM
KY430056263OtherRAILROAD MEDICARE
KY74408006Medicaid
KY74408006Medicaid