Provider Demographics
NPI:1053349787
Name:FIACCO, CINDY L (PA)
Entity type:Individual
Prefix:
First Name:CINDY
Middle Name:L
Last Name:FIACCO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:201 SIGMA DR STE 100
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7722
Mailing Address - Country:US
Mailing Address - Phone:843-695-6071
Mailing Address - Fax:843-569-5879
Practice Address - Street 1:115 EXECUTIVE PKWY
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461
Practice Address - Country:US
Practice Address - Phone:843-761-2815
Practice Address - Fax:843-899-4723
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2018-06-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC466363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1032PAMedicaid
SCAA52486834Medicare PIN