Provider Demographics
NPI:1760780803
Name:BOOZE, LORAINE ELIZABETH (PA-C)
Entity type:Individual
Prefix:
First Name:LORAINE
Middle Name:ELIZABETH
Last Name:BOOZE
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 749306
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-9306
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3424 SHELBY RAY CT
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-5838
Practice Address - Country:US
Practice Address - Phone:843-402-6834
Practice Address - Fax:843-573-9963
Is Sole Proprietor?:No
Enumeration Date:2011-03-13
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1620363AM0700X
SC363A00000X363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1620OtherSOUTH CAROLINA PHYSICIAN ASSISTANT LICENSURE
SC1620OtherSOUTH CAROLINA PHYSICIAN ASSISTANT LICENSURE