Healthcare Provider Details

I. General information

NPI: 1720739733
Provider Name (Legal Business Name): LAURA A. KHOURY PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 OLD TROLLEY RD STE 300
SUMMERVILLE SC
29485-5294
US

IV. Provider business mailing address

724 RALSTON CT
MT PLEASANT SC
29464-3572
US

V. Phone/Fax

Practice location:
  • Phone: 843-376-2670
  • Fax: 843-376-2790
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number4304
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: