Provider Demographics
NPI:1720414733
Name:SUMNER, MEGAN OLIVER (PA)
Entity type:Individual
Prefix:
First Name:MEGAN
Middle Name:OLIVER
Last Name:SUMNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:ELIZABETH
Other - Last Name:OLIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
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 1:743 FOLLY RD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-3432
Practice Address - Country:US
Practice Address - Phone:843-762-2360
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-23
Last Update Date:2024-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1964363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1804PAMedicaid