Provider Demographics
NPI:1356374334
Name:CAWTHON, WANDA (ANP)
Entity type:Individual
Prefix:MS
First Name:WANDA
Middle Name:
Last Name:CAWTHON
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 48TH AVENUE N
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577
Mailing Address - Country:US
Mailing Address - Phone:843-449-1000
Mailing Address - Fax:843-449-1009
Practice Address - Street 1:1211 48TH AVENUE N
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577
Practice Address - Country:US
Practice Address - Phone:843-449-1000
Practice Address - Fax:843-449-1009
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA17675363LA2200X
GARN072630363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000498825DMedicaid
GAR82924Medicare UPIN