Provider Demographics
NPI:1992756233
Name:SPOHR, TERRY L (PA-C)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:L
Last Name:SPOHR
Suffix:
Gender:M
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 1:229 S. 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:ST. MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861
Mailing Address - Country:US
Mailing Address - Phone:208-245-2591
Mailing Address - Fax:208-245-5246
Practice Address - Street 1:229 S. 7TH STREET
Practice Address - Street 2:
Practice Address - City:ST. MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861
Practice Address - Country:US
Practice Address - Phone:208-245-2591
Practice Address - Fax:208-245-5246
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA28363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID002790900Medicaid
ID970003235OtherRAILROAD MEDICARE
ID1185830001OtherMEDICARE DMERC
IDP31361Medicare UPIN
ID1665245Medicare ID - Type Unspecified