Provider Demographics
NPI:1881741890
Name:REDMOND, SHAKISHA T (PAC)
Entity type:Individual
Prefix:
First Name:SHAKISHA
Middle Name:T
Last Name:REDMOND
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 HENDERSON ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29201-2619
Mailing Address - Country:US
Mailing Address - Phone:803-276-2186
Mailing Address - Fax:803-276-2630
Practice Address - Street 1:2605 KINARD ST
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWBERRY
Practice Address - State:SC
Practice Address - Zip Code:29108-2967
Practice Address - Country:US
Practice Address - Phone:803-405-1900
Practice Address - Fax:803-405-1919
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA889363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1202PAMedicaid
SCAA1192Medicare PIN
SCQ60106Medicare UPIN