Provider Demographics
NPI:1730188517
Name:D'ANTONI, JENNIFER G (PA)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:G
Last Name:D'ANTONI
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:CATHERINE
Other - Last Name:GRASHA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3231 SUNSET BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29169-3483
Mailing Address - Country:US
Mailing Address - Phone:803-454-8500
Mailing Address - Fax:803-454-8505
Practice Address - Street 1:3231 SUNSET BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-3483
Practice Address - Country:US
Practice Address - Phone:803-454-8500
Practice Address - Fax:803-454-8505
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0307PAMedicaid
SCQ41342Medicare UPIN
SC0307PAMedicaid