Healthcare Provider Details

I. General information

NPI: 1467774042
Provider Name (Legal Business Name): SAMURDHI JAYAWEERA ROBERTS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2010
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 CARNES CROSSING BLVD STE B
SUMMERVILLE SC
29486-0407
US

IV. Provider business mailing address

PO BOX 632516
CINCINNATI OH
45263-2516
US

V. Phone/Fax

Practice location:
  • Phone: 843-212-8080
  • Fax: 843-203-2299
Mailing address:
  • Phone: 888-472-0043
  • Fax: 513-653-4122

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3822
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: