=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194939199
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARISA ROSE GRAHAM PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2007
-----------------------------------------------------
Last Update Date | 11/03/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1818 HENDERSON ST
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29201-2619
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-758-2602
-----------------------------------------------------
Fax | 803-253-8896
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 743 FOLLY RD
-----------------------------------------------------
City | CHARLESTON
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29412-3432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 828-762-2360
-----------------------------------------------------
Fax | 828-762-2340
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 0010-01328
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 1154
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------