Provider Demographics
NPI:1962785329
Name:PESEK, TERRY (PA-C)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:
Last Name:PESEK
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5791 NOEL ST
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44641-9321
Mailing Address - Country:US
Mailing Address - Phone:330-453-1897
Mailing Address - Fax:
Practice Address - Street 1:659 BOULEVARD
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:OH
Practice Address - Zip Code:44622
Practice Address - Country:US
Practice Address - Phone:330-364-0894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-22
Last Update Date:2012-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH003358363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant