Healthcare Provider Details

I. General information

NPI: 1154845717
Provider Name (Legal Business Name): CHRISTEN MARIE MACKORELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CHRISTEN MARIE HAIR

II. Dates (important events)

Enumeration Date: 07/26/2017
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 WESLEY DR STE 100
CHARLESTON SC
29407-7206
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-884-0302
  • Fax: 843-849-9308
Mailing address:
  • Phone: 888-472-0043
  • Fax: 843-724-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number2790
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: