Provider Demographics
NPI:1417936642
Name:KORPON, MARY LOU (CPNP)
Entity Type:Individual
Prefix:
First Name:MARY LOU
Middle Name:
Last Name:KORPON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 BENTONS LODGE RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-6322
Mailing Address - Country:US
Mailing Address - Phone:843-871-2588
Mailing Address - Fax:843-871-1664
Practice Address - Street 1:202 BENTONS LODGE RD
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29485-6322
Practice Address - Country:US
Practice Address - Phone:843-871-2588
Practice Address - Fax:843-871-1664
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN486363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0187Medicaid
SCQ31747Medicare UPIN