Healthcare Provider Details

I. General information

NPI: 1558950030
Provider Name (Legal Business Name): MIRIAM ISKANDAR OVERHOLSER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MIRIAM ISKANDAR GUIRGIS PA-C

II. Dates (important events)

Enumeration Date: 01/11/2021
Last Update Date: 01/11/2021
Certification Date: 01/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 MAIN ST
CONWAY SC
29526-3569
US

IV. Provider business mailing address

1031 FIDDLEHEAD WAY
MYRTLE BEACH SC
29579-3812
US

V. Phone/Fax

Practice location:
  • Phone: 843-438-8470
  • Fax:
Mailing address:
  • Phone: 843-446-5221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3762
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: