Provider Demographics
NPI:1932954153
Name:FOUNTAINE, SKYLER ALEXIS (PA-C)
Entity type:Individual
Prefix:
First Name:SKYLER
Middle Name:ALEXIS
Last Name:FOUNTAINE
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8906 TWO NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6366
Mailing Address - Country:US
Mailing Address - Phone:803-254-3676
Mailing Address - Fax:803-254-3678
Practice Address - Street 1:830 ROBERTSON BLVD
Practice Address - Street 2:
Practice Address - City:WALTERBORO
Practice Address - State:SC
Practice Address - Zip Code:29488-3081
Practice Address - Country:US
Practice Address - Phone:843-781-7428
Practice Address - Fax:843-781-7429
Is Sole Proprietor?:No
Enumeration Date:2024-04-22
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC7106PAMedicaid