Provider Demographics
NPI:1588815021
Name:MYNATT, JAMES ROBERT (FNP)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:ROBERT
Last Name:MYNATT
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:
Other - Last Name:MYNATT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:86 WREN ST
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812
Mailing Address - Country:US
Mailing Address - Phone:803-259-5762
Mailing Address - Fax:803-259-3250
Practice Address - Street 1:333 REVOLUTIONARY TRAIL
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:SC
Practice Address - Zip Code:29827
Practice Address - Country:US
Practice Address - Phone:803-632-2533
Practice Address - Fax:803-632-2451
Is Sole Proprietor?:No
Enumeration Date:2008-10-02
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCF1512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1512OtherMEDICAL LICENSE
SCNP0589Medicaid