Provider Demographics
NPI:1679501118
Name:DECKER, MARY K (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:K
Last Name:DECKER
Suffix:
Gender:F
Credentials:PA
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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 1:8091 RIVERS AVE
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9236
Practice Address - Country:US
Practice Address - Phone:843-572-7000
Practice Address - Fax:843-572-4070
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
SC710363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P48701Medicare UPIN