Healthcare Provider Details

I. General information

NPI: 1497704035
Provider Name (Legal Business Name): WANDA S COPELAND PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 04/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 D GAMECOCK AVE
CHARLESTON SC
29407-3368
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-763-7906
  • Fax: 843-763-1654
Mailing address:
  • Phone: 843-789-1620
  • Fax: 843-724-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number669
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: