Provider Demographics
NPI:1164729844
Name:CUSTER, SABRA S (DNP, FNP)
Entity Type:Individual
Prefix:DR
First Name:SABRA
Middle Name:S
Last Name:CUSTER
Suffix:
Gender:F
Credentials:DNP, FNP
Other - Prefix:
Other - First Name:SABRA
Other - Middle Name:H
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DNP,FNP
Mailing Address - Street 1:3555 HARDEN ST EXT
Mailing Address - Street 2:15 MEDICAL PARK STE 300
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6894
Mailing Address - Country:US
Mailing Address - Phone:803-545-5017
Mailing Address - Fax:803-255-3451
Practice Address - Street 1:1 MEDICAL PARK
Practice Address - Street 2:SUITE 420
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203
Practice Address - Country:US
Practice Address - Phone:803-545-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-02-16
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4273363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1824Medicaid
SCAA67312603Medicare PIN