Provider Demographics
NPI:1700430345
Name:GAUSE, KORREDA (PA-C)
Entity Type:Individual
Prefix:
First Name:KORREDA
Middle Name:
Last Name:GAUSE
Suffix:
Gender:F
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 1:1211 RAGIN ST
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29577-3375
Mailing Address - Country:US
Mailing Address - Phone:843-714-5720
Mailing Address - Fax:
Practice Address - Street 1:8120 ROURK ST
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-4127
Practice Address - Country:US
Practice Address - Phone:843-449-1438
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-31
Last Update Date:2019-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3259363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant