Healthcare Provider Details

I. General information

NPI: 1518923143
Provider Name (Legal Business Name): DAVID B LEE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2006
Last Update Date: 08/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 VILLAGE CENTER BLVD SUITE 200
MYRTLE BEACH SC
29579-6683
US

IV. Provider business mailing address

210 VILLAGE CENTER BLVD SUITE 200
MYRTLE BEACH SC
29579-6683
US

V. Phone/Fax

Practice location:
  • Phone: 843-236-3222
  • Fax: 843-236-3005
Mailing address:
  • Phone: 843-236-3222
  • Fax: 843-236-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number9990RS
License Number StateSC

VII. Legacy identifiers

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

# 1
Identifier0347PA
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: