Provider Demographics
NPI:1255387130
Name:LOOMAN, SHERRY A (PA)
Entity type:Individual
Prefix:
First Name:SHERRY
Middle Name:A
Last Name:LOOMAN
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:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1114 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-7326
Practice Address - Country:US
Practice Address - Phone:843-212-8070
Practice Address - Fax:843-212-8071
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2221363A00000X
NY006592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2396PAMedicaid
SCSC6987Medicare UPIN
SC2396PAMedicaid