Provider Demographics
NPI:1063797447
Name:CAROTHERS, MICHAEL B (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:B
Last Name:CAROTHERS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 TERRAPIN CIR
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-8273
Mailing Address - Country:US
Mailing Address - Phone:843-475-4392
Mailing Address - Fax:
Practice Address - Street 1:104 TERRAPIN CIR
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-8273
Practice Address - Country:US
Practice Address - Phone:843-475-4392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-17
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1922363AM0700X
PAMA055229363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC2059PAMedicaid