MEDICARE: CARRIE SUE KNIPE PAC

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	363A00000X	Physician Assistant	OA002163	PA
2	363A00000X	Physician Assistant	2288	SC

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
4	P00396195	OTHER	PA	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	02880931	OTHER	NY	NY MEDICAL ASSISTANCE
2	1765844	OTHER	PA	BLUE SHIELD
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1962408229
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARRIE SUE KNIPE PAC

Provider Business Mailing Address
First Line	:	PO BOX 743070
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-3070
Country	:	US
Telephone Number	:	814-877-5510
Fax Number	:	814-877-5518

Provider Business Practice Location Address
First Line	:	101 E WOOD ST
Second Line	:
City	:	SPARTANBURG
State	:	SC
Zip	:	29303-3040
Country	:	US
Telephone Number	:	864-560-6654
Fax Number	:

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

Provider Enumeration Date	:	06/22/2005
Last Update Date	:	01/29/2021

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Directions to “ CARRIE SUE KNIPE PAC” Practice Location

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