Provider Demographics
NPI:1841224854
Name:FETSCH, ERIN W (PA C)
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:W
Last Name:FETSCH
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2440
Practice Address - Street 1:3510 HIGHWAY 17 BYP N STE 105
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-8228
Practice Address - Country:US
Practice Address - Phone:843-789-1850
Practice Address - Fax:843-724-2551
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1079363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0554PAMedicaid
SCGP4857OtherMEDICAID GROUP
SC0554PAMedicaid
Q60431Medicare UPIN
SCAA11975551Medicare PIN