Provider Demographics
NPI:1528028602
Name:KOELE, DANIEL SCOT (PA)
Entity Type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:SCOT
Last Name:KOELE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 W CAROLINA AVE
Mailing Address - Street 2:
Mailing Address - City:HARTSVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29550-4524
Mailing Address - Country:US
Mailing Address - Phone:843-917-4977
Mailing Address - Fax:888-854-0390
Practice Address - Street 1:2829 E HIGHWAY 76
Practice Address - Street 2:
Practice Address - City:MULLINS
Practice Address - State:SC
Practice Address - Zip Code:29574-6035
Practice Address - Country:US
Practice Address - Phone:843-431-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA590363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC21820Medicaid
SCP269131271Medicare ID - Type UnspecifiedMEDICARE
SC21820Medicaid