Provider Demographics
NPI:1023477536
Name:TERRY, WHITNEY BROOKE (PA)
Entity type:Individual
Prefix:
First Name:WHITNEY
Middle Name:BROOKE
Last Name:TERRY
Suffix:
Gender:F
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:391 SERPENTINE DR STE 250
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303
Practice Address - Country:US
Practice Address - Phone:864-560-6717
Practice Address - Fax:864-560-7105
Is Sole Proprietor?:No
Enumeration Date:2016-02-12
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2955363A00000X
SCTL3012363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCD2697628OtherMEDICARE PIN
SC3675PAMedicaid
TN5542034OtherBCBS OF TN
TNQ020109Medicaid