Healthcare Provider Details

I. General information

NPI: 1306554225
Provider Name (Legal Business Name): MARY ANN BUCHANAN AGOSTINO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2022
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

877 W FARIS RD STE D
GREENVILLE SC
29605-4296
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-455-0931
  • Fax: 864-455-9014
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26712
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: