Healthcare Provider Details

I. General information

NPI: 1861157950
Provider Name (Legal Business Name): KATHERINE MAHAN CARROLL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2021
Last Update Date: 12/02/2021
Certification Date: 12/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9228 MEDICAL PLAZA DR
CHARLESTON SC
29406-9125
US

IV. Provider business mailing address

9228 MEDICAL PLAZA DR
CHARLESTON SC
29406-9125
US

V. Phone/Fax

Practice location:
  • Phone: 843-574-5693
  • Fax:
Mailing address:
  • Phone: 843-574-5693
  • Fax: 843-764-4512

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number4150
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4150
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: