Provider Demographics
NPI:1629577119
Name:MAJETIC, MICHAEL (ADV)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MAJETIC
Suffix:
Gender:M
Credentials:ADV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 SCHULTZ LAKE RD
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-9117
Mailing Address - Country:US
Mailing Address - Phone:724-513-1549
Mailing Address - Fax:
Practice Address - Street 1:110 SPRINGHALL DR
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-5335
Practice Address - Country:US
Practice Address - Phone:843-973-8503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-09
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10948363LA2200X
SCAPN.23998363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty