Provider Demographics
NPI:1639443948
Name:DISHAROON, JAMIE LEA
Entity Type:Individual
Prefix:MRS
First Name:JAMIE
Middle Name:LEA
Last Name:DISHAROON
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 1:120 GATEWAY CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-9611
Mailing Address - Country:US
Mailing Address - Phone:803-865-4500
Mailing Address - Fax:
Practice Address - Street 1:120 GATEWAY CORPORATE BLVD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9611
Practice Address - Country:US
Practice Address - Phone:803-865-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-05
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17864367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC17864OtherAPRN
SCRN107046OtherNURSING