Provider Demographics
NPI:1801093828
Name:IVEY, PAMELA LEE (PA)
Entity type:Individual
Prefix:
First Name:PAMELA
Middle Name:LEE
Last Name:IVEY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:PAMELA
Other - Middle Name:LEE
Other - Last Name:IVEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:110 PARRIS BRIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:BOILING SPRINGS
Mailing Address - State:SC
Mailing Address - Zip Code:29316
Mailing Address - Country:US
Mailing Address - Phone:864-599-1998
Mailing Address - Fax:864-599-9665
Practice Address - Street 1:110 PARRIS BRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:BOILING SPRINGS
Practice Address - State:SC
Practice Address - Zip Code:29316
Practice Address - Country:US
Practice Address - Phone:864-599-1998
Practice Address - Fax:864-599-9665
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA302363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q26757Medicare UPIN