Basic Information
| Provider Information | |||||||||
| NPI: | 1417540642 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WETHERELL | ||||||||
| FirstName: | SARAH | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 300 E MCBEE AVE FL 4 | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296012842 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032967320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8 RICHLAND MEDICAL PARK DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 292038008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8032566511 | ||||||||
| FaxNumber: | 8033765885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2021 | ||||||||
| LastUpdateDate: | 08/12/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3996 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 4845PA | 05 | SC | MEDICAID |