Provider Demographics
NPI:1942228044
Name:MANN, RICHARD ANTHONY JR (FNP-BC)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:ANTHONY
Last Name:MANN
Suffix:JR
Gender:M
Credentials:FNP-BC
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 485
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29202-0485
Mailing Address - Country:US
Mailing Address - Phone:803-898-8405
Mailing Address - Fax:808-898-8526
Practice Address - Street 1:901 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:CAYCE
Practice Address - State:SC
Practice Address - Zip Code:29033-3224
Practice Address - Country:US
Practice Address - Phone:803-791-3963
Practice Address - Fax:803-429-2134
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC899363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCGP4350Medicaid
SCS68425Medicare UPIN
SCGP4350Medicaid
SC5677Medicare PIN
SCS684253353Medicare PIN