Provider Demographics
NPI:1467629865
Name:PHILLIPS, KATHARINE MCCHESNEY (PA)
Entity type:Individual
Prefix:
First Name:KATHARINE
Middle Name:MCCHESNEY
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KATHARINE
Other - Middle Name:KAREN
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3400 WEST AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6901
Mailing Address - Country:US
Mailing Address - Phone:803-799-1700
Mailing Address - Fax:803-254-3678
Practice Address - Street 1:3400 WEST AVE
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6901
Practice Address - Country:US
Practice Address - Phone:803-799-1700
Practice Address - Fax:803-254-3678
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1300363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1192PAMedicaid
SCFQC088Medicaid