Provider Demographics
NPI:1376863654
Name:COGDILL, ALYSSA S (FNP)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:S
Last Name:COGDILL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:S
Other - Last Name:TOBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:PO BOX 743904
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3904
Mailing Address - Country:US
Mailing Address - Phone:803-296-7320
Mailing Address - Fax:803-296-7330
Practice Address - Street 1:9 RICHLAND MEDICAL PARK DR STE 110
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6859
Practice Address - Country:US
Practice Address - Phone:803-434-7961
Practice Address - Fax:803-434-7981
Is Sole Proprietor?:No
Enumeration Date:2010-06-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC204186363L00000X
SCAPN4253363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2389Medicare PIN
SCAA53292389Medicare UPIN