Healthcare Provider Details

I. General information

NPI: 1881741890
Provider Name (Legal Business Name): SHAKISHA T REDMOND PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 11/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 KINARD ST SUITE 200
NEWBERRY SC
29108-2967
US

IV. Provider business mailing address

1818 HENDERSON ST
COLUMBIA SC
29201-2619
US

V. Phone/Fax

Practice location:
  • Phone: 803-405-1900
  • Fax: 803-405-1919
Mailing address:
  • Phone: 803-276-2186
  • Fax: 803-276-2630

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberA889
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: