Provider Demographics
NPI:1679574370
Name:COTHRAN, CANDACE A (PA)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:A
Last Name:COTHRAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 27129
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29616-2129
Mailing Address - Country:US
Mailing Address - Phone:864-627-3800
Mailing Address - Fax:864-672-2654
Practice Address - Street 1:1202 E BUTLER RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-5910
Practice Address - Country:US
Practice Address - Phone:864-627-3800
Practice Address - Fax:864-672-2654
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA553207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy