Provider Demographics
NPI:1295554459
Name:PROCKIW, TAMMY (PA)
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:PROCKIW
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 1:1031 CHUCK DAWLEY BLVD STE 3
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4188
Mailing Address - Country:US
Mailing Address - Phone:843-425-6526
Mailing Address - Fax:
Practice Address - Street 1:1031 CHUCK DAWLEY BLVD STE 3
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-4188
Practice Address - Country:US
Practice Address - Phone:843-425-6526
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-05
Last Update Date:2024-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4165363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant