Provider Demographics
NPI:1821025529
Name:BOUKNIGHT, ANNA L (MD)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:L
Last Name:BOUKNIGHT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 DEVINE ST STE 101
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29205-2511
Mailing Address - Country:US
Mailing Address - Phone:803-256-7076
Mailing Address - Fax:803-256-0961
Practice Address - Street 1:2801 DEVINE ST STE 101
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29205-2511
Practice Address - Country:US
Practice Address - Phone:803-256-7076
Practice Address - Fax:803-256-0961
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC22059207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1647OtherMEDICARE
SCT62330Medicaid
SC1305Medicare PIN
SCPA1382OtherMEDICAID PTAN