Basic Information
Provider Information | |||||||||
NPI: | 1356686141 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROPER | ||||||||
FirstName: | ERICA | ||||||||
MiddleName: | COOLER | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | COOLER | ||||||||
OtherFirstName: | ERICA | ||||||||
OtherMiddleName: | LINDSEY | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA-C | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 955 RIBAUT RD | ||||||||
Address2: |   | ||||||||
City: | BEAUFORT | ||||||||
State: | SC | ||||||||
PostalCode: | 299025454 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8435227843 | ||||||||
FaxNumber: | 8435225945 | ||||||||
Practice Location | |||||||||
Address1: | 4818 BLUFFTON PKWY | ||||||||
Address2: |   | ||||||||
City: | BLUFFTON | ||||||||
State: | SC | ||||||||
PostalCode: | 299104602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8437060600 | ||||||||
FaxNumber: | 8339162116 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/05/2012 | ||||||||
LastUpdateDate: | 06/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 1869 | SC | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
ID | Type | State | Issuer | Description | 1668PA | 05 | SC |   | MEDICAID |