Provider Demographics
NPI:1912696956
Name:CALLAWAY, AVERY
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:
Last Name:CALLAWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 GARRETT RD
Mailing Address - Street 2:
Mailing Address - City:EDGEFIELD
Mailing Address - State:SC
Mailing Address - Zip Code:29824-2214
Mailing Address - Country:US
Mailing Address - Phone:803-257-1733
Mailing Address - Fax:
Practice Address - Street 1:158 GARRETT RD
Practice Address - Street 2:
Practice Address - City:EDGEFIELD
Practice Address - State:SC
Practice Address - Zip Code:29824-2214
Practice Address - Country:US
Practice Address - Phone:803-257-1733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical