Provider Demographics
NPI:1508496845
Name:WU, JEREMY KENT (CERTIFIED PA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:KENT
Last Name:WU
Suffix:
Gender:M
Credentials:CERTIFIED PA
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 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-777-7555
Mailing Address - Fax:843-777-7562
Practice Address - Street 1:800 E CHEVES ST STE 350
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2649
Practice Address - Country:US
Practice Address - Phone:843-777-7555
Practice Address - Fax:843-777-7563
Is Sole Proprietor?:No
Enumeration Date:2020-01-24
Last Update Date:2021-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPA2032363AS0400X
OH50.006024363AS0400X
SC4084363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical