Provider Demographics
NPI:1942633433
Name:EGBERS, KATIE MANTIE (PA)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:MANTIE
Last Name:EGBERS
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 1:1028 BANKER CT
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29429-4980
Mailing Address - Country:US
Mailing Address - Phone:203-687-1680
Mailing Address - Fax:
Practice Address - Street 1:316 CALHOUN ST
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29401-1113
Practice Address - Country:US
Practice Address - Phone:843-724-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-20
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC0010-06659363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1942633433Medicaid