MEDICARE: MS. MARSHA GAY DELAVAN PA C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	MPA319	SC

General Provider Information

NPI Number	:	1275597742
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARSHA GAY DELAVAN PA C

Provider Business Mailing Address
First Line	:	6060 HIGHWAY 165
Second Line	:
City	:	RAVENEL
State	:	SC
Zip	:	29470-5407
Country	:	US
Telephone Number	:	843-889-8982
Fax Number	:

Provider Business Practice Location Address
First Line	:	6180 HIGHWAY 162
Second Line	:
City	:	HOLLYWOOD
State	:	SC
Zip	:	29449-5767
Country	:	US
Telephone Number	:	843-889-8018
Fax Number	:	843-889-9133

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2006
Last Update Date	:	07/08/2007

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