Provider Demographics
NPI:1497704142
Name:SOUTH, REGINA (PA-C)
Entity Type:Individual
Prefix:MS
First Name:REGINA
Middle Name:
Last Name:SOUTH
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 1:130 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CARLETON
Mailing Address - State:MI
Mailing Address - Zip Code:48117-9461
Mailing Address - Country:US
Mailing Address - Phone:734-654-2169
Mailing Address - Fax:734-654-6535
Practice Address - Street 1:130 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:CARLETON
Practice Address - State:MI
Practice Address - Zip Code:48117-9461
Practice Address - Country:US
Practice Address - Phone:734-654-2169
Practice Address - Fax:734-654-6535
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601003551363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI231807Medicare PIN