Provider Demographics
NPI:1295828663
Name:HOLMES, TYSHA S (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:TYSHA
Middle Name:S
Last Name:HOLMES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 SUM MOR DR
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-4828
Mailing Address - Country:US
Mailing Address - Phone:803-244-9212
Mailing Address - Fax:
Practice Address - Street 1:103 SUM MOR DR
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4828
Practice Address - Country:US
Practice Address - Phone:803-244-9212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC734IM363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical