Healthcare Provider Details

I. General information

NPI: 1760898621
Provider Name (Legal Business Name): SUSAN CAUDLE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2014
Last Update Date: 08/25/2021
Certification Date: 08/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2750 LAUREL ST STE 305
COLUMBIA SC
29204-2025
US

IV. Provider business mailing address

PO BOX 935722
ATLANTA GA
31193-5722
US

V. Phone/Fax

Practice location:
  • Phone: 803-254-5140
  • Fax: 803-779-1279
Mailing address:
  • Phone: 843-792-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA 335
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: