Healthcare Provider Details

I. General information

NPI: 1962408229
Provider Name (Legal Business Name): CARRIE SUE KNIPE PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CARRIE S WALKER PAC

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 01/29/2021
Certification Date: 01/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E WOOD ST
SPARTANBURG SC
29303-3040
US

IV. Provider business mailing address

PO BOX 743070
ATLANTA GA
30374-3070
US

V. Phone/Fax

Practice location:
  • Phone: 864-560-6654
  • Fax:
Mailing address:
  • Phone: 814-877-5510
  • Fax: 814-877-5518

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberOA002163
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2288
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: