Provider Demographics
NPI:1306554225
Name:AGOSTINO, MARY ANN BUCHANAN (NP)
Entity type:Individual
Prefix:
First Name:MARY ANN
Middle Name:BUCHANAN
Last Name:AGOSTINO
Suffix:
Gender:F
Credentials:NP
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:877 W FARIS RD STE D
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4296
Practice Address - Country:US
Practice Address - Phone:864-455-0931
Practice Address - Fax:864-455-9014
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-09
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC26712363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid