Provider Demographics
NPI:1275653461
Name:RUSE, ERIN KELLEY (PA)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:KELLEY
Last Name:RUSE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:ERIN
Other - Middle Name:L
Other - Last Name:KELLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:2093 HENRY TECKLENBURG DR STE 300E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5743
Practice Address - Country:US
Practice Address - Phone:843-724-2011
Practice Address - Fax:843-606-7991
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1202363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1066PAMedicaid
SCQ78297Medicare UPIN
SCAA18085684Medicare PIN