Provider Demographics
NPI:1376909325
Name:DEVLIN, BRIAN JOHN (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOHN
Last Name:DEVLIN
Suffix:
Gender:M
Credentials:PA-C
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 601843
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1843
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1530 PROVIDENCE RD S
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-8313
Practice Address - Country:US
Practice Address - Phone:704-627-8365
Practice Address - Fax:704-627-8366
Is Sole Proprietor?:No
Enumeration Date:2016-01-06
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06201363A00000X
NC363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant