Provider Demographics
NPI:1922775493
Name:OGLESBY, ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:OGLESBY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 E STONE AVE APT 210
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2252
Mailing Address - Country:US
Mailing Address - Phone:502-619-3901
Mailing Address - Fax:
Practice Address - Street 1:2498 N PLEASANTBURG DR
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29609-2730
Practice Address - Country:US
Practice Address - Phone:864-503-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant