Provider Demographics
NPI:1790025443
Name:GORANSON, REBECCA D (PA)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:D
Last Name:GORANSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:A
Other - Last Name:DAUBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:104 SALUDA POINTE DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:SC
Mailing Address - Zip Code:29072-7295
Mailing Address - Country:US
Mailing Address - Phone:803-227-9178
Mailing Address - Fax:803-227-8278
Practice Address - Street 1:104 SALUDA POINTE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072-7295
Practice Address - Country:US
Practice Address - Phone:803-227-9178
Practice Address - Fax:803-227-8278
Is Sole Proprietor?:No
Enumeration Date:2013-02-18
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC363A00000X
SC1902363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant