Healthcare Provider Details

I. General information

NPI: 1841811437
Provider Name (Legal Business Name): MR. JONATHAN TANNER HODGIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 03/24/2026
Certification Date: 03/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 THE PKWY
GREER SC
29650-4569
US

IV. Provider business mailing address

310 THE PKWY
GREER SC
29650-4569
US

V. Phone/Fax

Practice location:
  • Phone: 864-877-0776
  • Fax: 864-877-0778
Mailing address:
  • Phone: 864-877-0776
  • Fax: 864-877-0778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3823
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: