Provider Demographics
NPI:1740433440
Name:POWELL, ELIZABETH LAUREN (PA)
Entity type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:LAUREN
Last Name:POWELL
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: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:843-724-2440
Practice Address - Street 1:3400 SALTERBECK CT
Practice Address - Street 2:SUITE 100
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29466-7118
Practice Address - Country:US
Practice Address - Phone:843-971-3361
Practice Address - Fax:843-971-8492
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1372363AM0700X
SCLL1372363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00813750OtherRAILROAD MEDICARE ID-RSFPN
SC0731PAMedicaid
SCAA33839223Medicare PIN