Provider Demographics
NPI:1467878306
Name:FERGUSON, KASHAE (APN)
Entity Type:Individual
Prefix:
First Name:KASHAE
Middle Name:
Last Name:FERGUSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 602120
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2120
Mailing Address - Country:US
Mailing Address - Phone:803-835-0420
Mailing Address - Fax:704-512-2231
Practice Address - Street 1:704 GOLD HILL RD
Practice Address - Street 2:SUITE 107
Practice Address - City:FORT MILL
Practice Address - State:SC
Practice Address - Zip Code:29715-8906
Practice Address - Country:US
Practice Address - Phone:803-835-0420
Practice Address - Fax:704-512-2231
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-17
Last Update Date:2015-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00487500363LF0000X
SC19382363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP3233Medicaid
SCSC63604592Medicare PIN