Provider Demographics
NPI:1548021801
Name:PAYNE, JACK ANDREW (PA)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:ANDREW
Last Name:PAYNE
Suffix:
Gender:M
Credentials:PA
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 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:843-572-7727
Mailing Address - Fax:
Practice Address - Street 1:7 S ALLIANCE DR STE 211B
Practice Address - Street 2:
Practice Address - City:GOOSE CREEK
Practice Address - State:SC
Practice Address - Zip Code:29445-7297
Practice Address - Country:US
Practice Address - Phone:843-553-4383
Practice Address - Fax:843-553-4384
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC5179363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant