Healthcare Provider Details

I. General information

NPI: 1710224001
Provider Name (Legal Business Name): CARLY SCHNEIDER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2013
Last Update Date: 03/11/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 SASANQUA DR
GRANITEVILLE SC
29829
US

IV. Provider business mailing address

367 S. GULPH RD ATTN: IPM CREDENTIALING
KING OF PRUSSIA PA
19406-3121
US

V. Phone/Fax

Practice location:
  • Phone: 803-392-1811
  • Fax: 803-761-6247
Mailing address:
  • Phone: 803-392-1811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1873
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: