Provider Demographics
NPI:1376981316
Name:LOOMIS, AMANDA RAE (PA-C)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:RAE
Last Name:LOOMIS
Suffix:
Gender:F
Credentials:PA-C
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 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-777-7900
Mailing Address - Fax:843-777-7925
Practice Address - Street 1:800 E CHEVES ST
Practice Address - Street 2:SUITE 480
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2650
Practice Address - Country:US
Practice Address - Phone:843-777-7900
Practice Address - Fax:843-777-7925
Is Sole Proprietor?:No
Enumeration Date:2013-06-12
Last Update Date:2014-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCPA1946363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC286371OtherMEDCOST
SC8495247OtherCIGNA
SC1745PAMedicaid