Provider Demographics
NPI:1487608287
Name:LANDRY, PATRICIA A (MD)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:A
Last Name:LANDRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2089
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29641-2089
Mailing Address - Country:US
Mailing Address - Phone:864-855-5104
Mailing Address - Fax:864-859-9362
Practice Address - Street 1:309 E 1ST AVE
Practice Address - Street 2:
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-3040
Practice Address - Country:US
Practice Address - Phone:864-859-6331
Practice Address - Fax:864-855-1045
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC582296052-528OtherBLUE CROSS
SC160159Medicaid
SCF30542Medicare UPIN
SCF305429368Medicare PIN
SCF305425737Medicare PIN