Provider Demographics
NPI:1538636345
Name:SVANTESSON, MARIAH JORDAN (PA)
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:JORDAN
Last Name:SVANTESSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARIAH
Other - Middle Name:JORDAN
Other - Last Name:MCCALLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:851 LEONARD FULGHUM DR STE 101
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3793
Mailing Address - Country:US
Mailing Address - Phone:843-971-9350
Mailing Address - Fax:843-971-9351
Practice Address - Street 1:851 LEONARD FULGHUM DR STE 101
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3793
Practice Address - Country:US
Practice Address - Phone:843-971-9350
Practice Address - Fax:843-971-9351
Is Sole Proprietor?:No
Enumeration Date:2018-10-30
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3098363AS0400X, 207XX0005X
COPA.0006527363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine