Healthcare Provider Details

I. General information

NPI: 1275597742
Provider Name (Legal Business Name): MARSHA GAY DELAVAN PA C
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6180 HIGHWAY 162
HOLLYWOOD SC
29449-5767
US

IV. Provider business mailing address

6060 HIGHWAY 165
RAVENEL SC
29470-5407
US

V. Phone/Fax

Practice location:
  • Phone: 843-889-8018
  • Fax: 843-889-9133
Mailing address:
  • Phone: 843-889-8982
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMPA319
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: