Healthcare Provider Details

I. General information

NPI: 1346350089
Provider Name (Legal Business Name): AMY ROSE HANCOCK PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 06/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 OLEANDER DR SUITE # 1
MYRTLE BEACH SC
29577-5897
US

IV. Provider business mailing address

200 E BROAD ST SUITE # 220
GREENVILLE SC
29601-2887
US

V. Phone/Fax

Practice location:
  • Phone: 864-343-2609
  • Fax: 864-546-4506
Mailing address:
  • Phone: 864-343-2609
  • Fax: 864-546-4506

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberOA002612
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2433
Identifier TypeOTHER
Identifier StateSC
Identifier IssuerSOUTH CAROLINA MEDICAL LICENSE
# 2
IdentifierPN084501L
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerPA STATE LICENSE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: