Provider Demographics
NPI:1265823876
Name:VANDERBILT, TANIA C (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MRS
First Name:TANIA
Middle Name:C
Last Name:VANDERBILT
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 DEER TRACK RD
Mailing Address - Street 2:
Mailing Address - City:SIMPSONVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29681-4764
Mailing Address - Country:US
Mailing Address - Phone:803-467-1446
Mailing Address - Fax:
Practice Address - Street 1:525 VERDAE BLVD STE 200
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4021
Practice Address - Country:US
Practice Address - Phone:864-272-0388
Practice Address - Fax:864-213-9273
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2193363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant