Provider Demographics
NPI:1790767697
Name:DEMIZIO, JANA W (PA-C)
Entity Type:Individual
Prefix:MS
First Name:JANA
Middle Name:W
Last Name:DEMIZIO
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:300 SCUFFLETOWN RD
Practice Address - Street 2:
Practice Address - City:SIMPSONVILLE
Practice Address - State:SC
Practice Address - Zip Code:29681-7204
Practice Address - Country:US
Practice Address - Phone:864-522-1550
Practice Address - Fax:864-522-1555
Is Sole Proprietor?:No
Enumeration Date:2005-11-16
Last Update Date:2021-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC824363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0284PAMedicaid
SC0284PAMedicaid
SCP87369Medicare UPIN
SCP873696909Medicare PIN
SCAA97507951Medicare PIN
SCP873696912Medicare PIN