Provider Demographics
NPI:1386650430
Name:DATWYLER, DAVID MERRILL
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:MERRILL
Last Name:DATWYLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 NOB HILL RD
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29307-3509
Mailing Address - Country:US
Mailing Address - Phone:864-879-9338
Mailing Address - Fax:
Practice Address - Street 1:1700 SKYLYN DR
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1041
Practice Address - Country:US
Practice Address - Phone:864-573-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN961367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN0639Medicaid
SCQ31583Medicare UPIN
SCAN0639Medicaid