Healthcare Provider Details

I. General information

NPI: 1639443948
Provider Name (Legal Business Name): MRS. JAMIE LEA DISHAROON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2012
Last Update Date: 10/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 GATEWAY CORPORATE BLVD
COLUMBIA SC
29203-9611
US

IV. Provider business mailing address

120 GATEWAY CORPORATE BLVD
COLUMBIA SC
29203-9611
US

V. Phone/Fax

Practice location:
  • Phone: 803-865-4500
  • Fax:
Mailing address:
  • Phone: 803-865-4500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number17864
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: