Healthcare Provider Details

I. General information

NPI: 1811627581
Provider Name (Legal Business Name): MALLORY MARIE CAUTHEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2022
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 W MEETING ST STE 101
LANCASTER SC
29720-2245
US

IV. Provider business mailing address

1025 W MEETING ST STE 101
LANCASTER SC
29720-2245
US

V. Phone/Fax

Practice location:
  • Phone: 803-416-5453
  • Fax: 803-416-5456
Mailing address:
  • Phone: 803-416-5453
  • Fax: 803-416-5456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4799
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: