Healthcare Provider Details

I. General information

NPI: 1760942759
Provider Name (Legal Business Name): VIRGINIA ERIN MASHACK DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2019
Last Update Date: 06/29/2022
Certification Date: 06/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9228 MEDICAL PLAZA DR
CHARLESTON SC
29406-9125
US

IV. Provider business mailing address

9818 DOMINION FOREST CIR
FREDERICKSBURG VA
22408-9508
US

V. Phone/Fax

Practice location:
  • Phone: 843-876-7080
  • Fax:
Mailing address:
  • Phone: 434-250-3765
  • Fax:

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 StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberLL82244
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: