Provider Demographics
NPI:1831101385
Name:LAROCHE, MALISSA ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:ANN
Last Name:LAROCHE
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 1:1101 CLARITY RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-3138
Mailing Address - Country:US
Mailing Address - Phone:843-793-5437
Mailing Address - Fax:843-375-1487
Practice Address - Street 1:1101 CLARITY RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-3138
Practice Address - Country:US
Practice Address - Phone:843-793-5437
Practice Address - Fax:843-375-1487
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA635363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP33068Medicare UPIN