Provider Demographics
NPI:1497704035
Name:COPELAND, WANDA S (PA C)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:S
Last Name:COPELAND
Suffix:
Gender:F
Credentials:PA C
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 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:21 D GAMECOCK AVE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-3368
Practice Address - Country:US
Practice Address - Phone:843-763-7906
Practice Address - Fax:843-763-1654
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2010-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC669363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0207PAMedicaid
SCP00803328OtherRAILROAD MEDICARE ID-RSFPN
SCP22413Medicare UPIN
SCP224139223Medicare PIN
SCP224135904Medicare PIN