Provider Demographics
NPI:1295704906
Name:PFENINGER, GREGORY R (PA C)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:R
Last Name:PFENINGER
Suffix:
Gender:M
Credentials:PA C
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:843-789-1620
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:843-724-2450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2032363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV322OtherTHE HEALTH PLAN
124508400OtherDEPT OF LABOR WORK COMP
SC1840PAMedicaid
198177OtherFEDERAL BLACK LUNG
P00178506OtherRAILROAD MEDICARE
Q22014OtherCARELINK
Q22014OtherCARELINK
001714976OtherMT STATE BLUE CROSS BLUE
WV322OtherTHE HEALTH PLAN
Q22014Medicare UPIN
001714976OtherMT STATE BLUE CROSS BLUE
Q22014OtherCARELINK
WVPFPA23313Medicare PIN