Individual
SHANNAH WICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA
Contact information
Practice address
853 N CHURCH ST STE 720C, SPARTANBURG, SC 29303-3003
(864) 560-6419
Mailing address
PO BOX 743070, ATLANTA, GA 30374-3070
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
0010-03218
NC
363A00000X
Physician Assistant
Primary
3483
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
2075PA
—
SC
01
—
SCH4256066
MEDICARE PIN
SC
Enumeration date
11/09/2011
Last updated
05/01/2020
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