Healthcare Provider Details

I. General information

NPI: 1376877274
Provider Name (Legal Business Name): AUSPRIA S WADE PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUSPRIA S DOUGLAS

II. Dates (important events)

Enumeration Date: 09/24/2009
Last Update Date: 02/25/2021
Certification Date: 02/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 SAINT ANDREWS RD STE 2
COLUMBIA SC
29210-5120
US

IV. Provider business mailing address

612 SAINT ANDREWS RD STE 2
COLUMBIA SC
29210-5120
US

V. Phone/Fax

Practice location:
  • Phone: 803-386-8684
  • Fax:
Mailing address:
  • Phone: 803-386-8684
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005354
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3458
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: