Healthcare Provider Details

I. General information

NPI: 1679574370
Provider Name (Legal Business Name): CANDACE A COTHRAN PA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/03/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 E BUTLER RD
GREENVILLE SC
29607-5910
US

IV. Provider business mailing address

PO BOX 27129
GREENVILLE SC
29616-2129
US

V. Phone/Fax

Practice location:
  • Phone: 864-627-3800
  • Fax: 864-672-2654
Mailing address:
  • Phone: 864-627-3800
  • Fax: 864-672-2654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License NumberA553
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: