Healthcare Provider Details

I. General information

NPI: 1619004801
Provider Name (Legal Business Name): SUSAN MARIE KAMINSKI PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 11/03/2024
Certification Date: 11/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1113 CHURCH ST
CONWAY SC
29526-4128
US

IV. Provider business mailing address

PO BOX 749306
ATLANTA GA
30374-9306
US

V. Phone/Fax

Practice location:
  • Phone: 843-248-6269
  • Fax: 843-248-0535
Mailing address:
  • Phone: 843-248-6269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA 002171-L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3312
License Number StateSC
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3312
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: