Provider Demographics
NPI:1942086400
Name:FUSCO, CARLIE DEE
Entity Type:Individual
Prefix:
First Name:CARLIE
Middle Name:DEE
Last Name:FUSCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 TWISTED HILL RD
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2049
Mailing Address - Country:US
Mailing Address - Phone:843-465-1623
Mailing Address - Fax:
Practice Address - Street 1:407 N BROWN ST
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-5710
Practice Address - Country:US
Practice Address - Phone:803-995-8963
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-31
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant