Healthcare Provider Details

I. General information

NPI: 1740713668
Provider Name (Legal Business Name): WILLIAM NATHANIEL GASQUE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: NATHAN GASQUE MD

II. Dates (important events)

Enumeration Date: 04/07/2017
Last Update Date: 07/18/2023
Certification Date: 07/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3793 MCDOWELL LANE SUITE 100
LITTLE RIVER SC
29566
US

IV. Provider business mailing address

3793 MCDOWELL LANE SUITE 100
LITTLE RIVER SC
29566
US

V. Phone/Fax

Practice location:
  • Phone: 843-390-0100
  • Fax: 843-390-0038
Mailing address:
  • Phone: 843-390-0100
  • Fax: 843-390-0038

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number51148
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: