Provider Demographics
NPI:1649221854
Name:MAULDIN, LORI P (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:P
Last Name:MAULDIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1706 SAINT JULIAN PL
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2410
Mailing Address - Country:US
Mailing Address - Phone:803-771-7506
Mailing Address - Fax:803-771-9455
Practice Address - Street 1:1706 SAINT JULIAN PL
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2410
Practice Address - Country:US
Practice Address - Phone:803-771-7506
Practice Address - Fax:803-771-9455
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC920207N00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA08524810Medicare UPIN