Healthcare Provider Details

I. General information

NPI: 1013223262
Provider Name (Legal Business Name): KEVIN ROBERT MONAGHAN PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2010
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8004 MYRTLE TRACE DRIVE SUITE 200
CONWAY SC
29526-2952
US

IV. Provider business mailing address

300 SINGLETON RIDGE ROAD ATTENTION PATIENT ACCOUNTING
CONWAY SC
29526-9142
US

V. Phone/Fax

Practice location:
  • Phone: 843-347-8041
  • Fax: 843-347-8042
Mailing address:
  • Phone: 843-234-6946
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA054492
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3517
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: