Provider Demographics
NPI:1558307033
Name:CARRICO, DEANNA L
Entity Type:Individual
Prefix:
First Name:DEANNA
Middle Name:L
Last Name:CARRICO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4416 FOREST DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29206-3104
Mailing Address - Country:US
Mailing Address - Phone:803-782-4278
Mailing Address - Fax:803-782-3445
Practice Address - Street 1:1851 SAM RITTENBERG BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4870
Practice Address - Country:US
Practice Address - Phone:843-556-5585
Practice Address - Fax:843-556-5587
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC958363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AA0653Medicare ID - Type Unspecified
Q25901Medicare UPIN