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NPI Code Detail

MEDICARE: MIRAKLE AVERY

MEDICARE: MIRAKLE AVERY
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant6095SC

General Provider Information

NPI Number : 1013772391
Entity Type Code : Individual
Provider Name (Legal Business Name) : MIRAKLE AVERY
Provider Business Mailing Address
First Line : 2611 FOREST DR STE 200
Second Line :
City : COLUMBIA
State : SC
Zip : 29204-2371
Country : US
Telephone Number : 804-799-3263
Fax Number :
Provider Business Practice Location Address
First Line : 2611 FOREST DR STE 200
Second Line :
City : COLUMBIA
State : SC
Zip : 29204-2371
Country : US
Telephone Number : 803-799-3263
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/16/2024
Last Update Date : 01/15/2026

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Directions to “ MIRAKLE AVERY ” Practice Location

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These directions are for planning purposes only. You may find that construction projects, traffic, or other events may cause road conditions to differ from the map results.

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