Provider Demographics
NPI:1750855011
Name:MOODY, EMILY (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:MOODY
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:PO BOX 100174
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-3174
Mailing Address - Country:US
Mailing Address - Phone:864-512-6810
Mailing Address - Fax:864-224-1109
Practice Address - Street 1:2000 E GREENVILLE ST STE 2500
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-1728
Practice Address - Country:US
Practice Address - Phone:864-512-6810
Practice Address - Fax:864-224-1109
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-18
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3138363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant