Basic Information
| Provider Information | |||||||||
| NPI: | 1487608287 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LANDRY | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2089 | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296412089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648555104 | ||||||||
| FaxNumber: | 8648599362 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 E 1ST AVE | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296403040 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648596331 | ||||||||
| FaxNumber: | 8648551045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/19/2006 | ||||||||
| LastUpdateDate: | 02/27/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 16015 | SC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 582296052-528 | 01 | SC | BLUE CROSS | OTHER | 160159 | 05 | SC | MEDICAID |