Provider Demographics
NPI:1811627581
Name:CAUTHEN, MALLORY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:MARIE
Last Name:CAUTHEN
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 1:114 GATEWAY CORPORATE BLVD STE 230
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-9785
Mailing Address - Country:US
Mailing Address - Phone:803-365-8640
Mailing Address - Fax:
Practice Address - Street 1:114 GATEWAY CORPORATE BLVD STE 230
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9785
Practice Address - Country:US
Practice Address - Phone:803-365-8640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-14
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4799363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant