Provider Demographics
NPI:1821144304
Name:KUTCH, PHYLLIS J (PA-C)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:J
Last Name:KUTCH
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 1:11 JENKINS ST
Mailing Address - Street 2:
Mailing Address - City:MAULDIN
Mailing Address - State:SC
Mailing Address - Zip Code:29662-2412
Mailing Address - Country:US
Mailing Address - Phone:864-288-1941
Mailing Address - Fax:864-288-1946
Practice Address - Street 1:11 JENKINS STREET
Practice Address - Street 2:
Practice Address - City:MAULDIN
Practice Address - State:SC
Practice Address - Zip Code:29662-2412
Practice Address - Country:US
Practice Address - Phone:864-288-1941
Practice Address - Fax:864-288-1946
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA1165363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0506PAMedicaid
SCGP4225OtherMEDICAID GROUP NUMBER
SC8272OtherMEDICARE GROUP NUMBER
SC0506PAMedicaid
SCS77909Medicare UPIN