MEDICARE: MS. LISA MARIE SAND PA-C

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
1	363AS0400X	Surgical Physician Assistant	A317	SC
2	363A00000X	Physician Assistant	317	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	A317	OTHER	SC	STATE LICENSURE NUMBER

General Provider Information

NPI Number	:	1578514428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA MARIE SAND PA-C

Provider Business Mailing Address
First Line	:	PO BOX 935722
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	31193-5722
Country	:	US
Telephone Number	:	843-792-6200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1655 BERNARDIN AVE STE 350
Second Line	:
City	:	COLUMBIA
State	:	SC
Zip	:	29204-2039
Country	:	US
Telephone Number	:	803-673-0925
Fax Number	:	803-400-5026

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/15/2006
Last Update Date	:	08/25/2021

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Directions to “ MS. LISA MARIE SAND PA-C” Practice Location

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