Provider Demographics
NPI:1386668648
Name:GLOVER, VICKIE (PA)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:
Last Name:GLOVER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VICKIE
Other - Middle Name:
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:86 WREN STREET
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812
Mailing Address - Country:US
Mailing Address - Phone:803-259-5762
Mailing Address - Fax:803-259-3050
Practice Address - Street 1:13649 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:SC
Practice Address - Zip Code:29853
Practice Address - Country:US
Practice Address - Phone:803-266-0060
Practice Address - Fax:803-266-0042
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC00047961363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0020PAMedicaid
SCP19236OtherMEDICARE
SCFQC044Medicaid