Provider Demographics
NPI:1245296797
Name:MINOR, DEMERISE OTT (FNP)
Entity type:Individual
Prefix:
First Name:DEMERISE
Middle Name:OTT
Last Name:MINOR
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:R. DEMERISE
Other - Middle Name:OTT
Other - Last Name:MINOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:3 RICHLAND MEDICAL PARK DR
Practice Address - Street 2:SUITE 310
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6849
Practice Address - Country:US
Practice Address - Phone:803-434-8323
Practice Address - Fax:803-434-8326
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN766363LA2100X
SC766363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0587Medicaid
SCNP0587Medicaid
SCP530718946Medicare PIN
SCP530711955Medicare PIN
P53071Medicare UPIN