Provider Demographics
NPI:1942614607
Name:ACKERSON, MEGAN WILDEROTTER (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:WILDEROTTER
Last Name:ACKERSON
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 1:120 GATEWAY CORPORATE BLVD
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-9611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 GATEWAY CORPORATE BLVD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-9611
Practice Address - Country:US
Practice Address - Phone:803-256-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA307587363A00000X, 363AM0700X
SCPA2122363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant