Basic Information
| Provider Information | |||||||||
| NPI: | 1962913921 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GRISHAM | ||||||||
| FirstName: | ALYSSA | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 6069 | ||||||||
| Address2: | |||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291716069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037912350 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2720 SUNSET BLVD | ||||||||
| Address2: | |||||||||
| City: | WEST COLUMBIA | ||||||||
| State: | SC | ||||||||
| PostalCode: | 291694810 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8039394577 | ||||||||
| FaxNumber: | 8037944317 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2017 | ||||||||
| LastUpdateDate: | 11/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 3112 | SC | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 363AM0700X | 3112 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.