Healthcare Provider Details

I. General information

NPI: 1396248357
Provider Name (Legal Business Name): ETHAN WALL VARNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/15/2018
Last Update Date: 04/24/2023
Certification Date: 04/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2067 CHARLIE HALL BLVD
CHARLESTON SC
29414-5834
US

IV. Provider business mailing address

4975 LACROSS RD STE 150
NORTH CHARLESTON SC
29406-6531
US

V. Phone/Fax

Practice location:
  • Phone: 843-573-2535
  • Fax:
Mailing address:
  • Phone: 843-737-9467
  • Fax: 843-371-5507

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number89369
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: