Provider Demographics
NPI:1346350089
Name:HANCOCK, AMY ROSE (PAC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ROSE
Last Name:HANCOCK
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E BROAD ST
Mailing Address - Street 2:SUITE # 220
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2887
Mailing Address - Country:US
Mailing Address - Phone:864-343-2609
Mailing Address - Fax:864-546-4506
Practice Address - Street 1:4900 OLEANDER DR
Practice Address - Street 2:SUITE # 1
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-5897
Practice Address - Country:US
Practice Address - Phone:864-343-2609
Practice Address - Fax:864-546-4506
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA002612363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2433OtherSOUTH CAROLINA MEDICAL LICENSE
PAPN084501LOtherPA STATE LICENSE
PAPN084501LOtherPA STATE LICENSE
SC2433OtherSOUTH CAROLINA MEDICAL LICENSE