Provider Demographics
NPI:1407322167
Name:BETTIS, MEGAN KIRKLAND
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:KIRKLAND
Last Name:BETTIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:ANNETTE
Other - Last Name:KIRKLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
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:803-549-0221
Mailing Address - Fax:
Practice Address - Street 1:300 PALMETTO HEALTH PKWY STE 200
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29212-1762
Practice Address - Country:US
Practice Address - Phone:803-296-7846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-22
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA3265363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4022PAMedicaid