Provider Demographics
NPI:1447278569
Name:STRICKLAND, GWENDOLYN G (PA)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:G
Last Name:STRICKLAND
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1205 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:SC
Mailing Address - Zip Code:29571-2008
Mailing Address - Country:US
Mailing Address - Phone:843-423-0760
Mailing Address - Fax:843-423-8138
Practice Address - Street 1:1600 HIGHWAY 17 N
Practice Address - Street 2:
Practice Address - City:SURFSIDE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29575-6015
Practice Address - Country:US
Practice Address - Phone:843-238-1461
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA238363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0889PAMedicaid
SCGP5462OtherGROUP MEDICAID
423852Medicare ID - Type Unspecified
SC0889PAMedicaid
SCAA45209493Medicare PIN