Provider Demographics
NPI:1942342142
Name:HART, DAVID ROGERS (PAC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:ROGERS
Last Name:HART
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:354 FOLLY RD STE 5
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-2594
Mailing Address - Country:US
Mailing Address - Phone:843-225-2374
Mailing Address - Fax:803-536-0998
Practice Address - Street 1:354 FOLLY RD STE 5
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-2594
Practice Address - Country:US
Practice Address - Phone:843-225-2374
Practice Address - Fax:434-591-9238
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA763FP363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0081PAMedicaid
SC3426Medicare PIN
P285723163Medicare ID - Type Unspecified