Provider Demographics
NPI:1790775385
Name:ALSWORTH, ROBERTA RAE (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:ROBERTA
Middle Name:RAE
Last Name:ALSWORTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:506 E CHEVES ST
Mailing Address - Street 2:SUITE 202
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2616
Mailing Address - Country:US
Mailing Address - Phone:843-777-7010
Mailing Address - Fax:843-777-7006
Practice Address - Street 1:945 82ND PKWY
Practice Address - Street 2:SUITE 3
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4610
Practice Address - Country:US
Practice Address - Phone:843-449-3381
Practice Address - Fax:843-839-0275
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-25
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCA362363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC5761191395Medicare ID - Type Unspecified
S76119Medicare UPIN