Provider Demographics
NPI:1225864788
Name:BISHOP, AMANDA GRACE
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:GRACE
Last Name:BISHOP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 CHUCK DAWLEY BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-4183
Mailing Address - Country:US
Mailing Address - Phone:843-884-8045
Mailing Address - Fax:
Practice Address - Street 1:1122 CHUCK DAWLEY BLVD STE 200
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-4183
Practice Address - Country:US
Practice Address - Phone:843-884-8045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-11
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC250155208800000X
SC29601363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No208800000XAllopathic & Osteopathic PhysiciansUrology