Provider Demographics
NPI:1710014477
Name:GOURLEY, TERRY LEE (PA)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:LEE
Last Name:GOURLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2900 DOOLITTLE DR
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH AFB
Mailing Address - State:SD
Mailing Address - Zip Code:57706-4821
Mailing Address - Country:US
Mailing Address - Phone:605-385-3111
Mailing Address - Fax:605-385-3680
Practice Address - Street 1:2900 DOOLITTLE DR
Practice Address - Street 2:
Practice Address - City:ELLSWORTH AFB
Practice Address - State:SD
Practice Address - Zip Code:57706-4821
Practice Address - Country:US
Practice Address - Phone:053-853-2736
Practice Address - Fax:308-367-4164
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE866363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE866OtherLICENSE
SD1029358OtherNCCPA CERT