Provider Demographics
NPI:1407815384
Name:BROWN, CAROLINE PRUITT (PA)
Entity Type:Individual
Prefix:
First Name:CAROLINE
Middle Name:PRUITT
Last Name:BROWN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1501 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-4734
Mailing Address - Country:US
Mailing Address - Phone:864-716-0063
Mailing Address - Fax:864-716-0073
Practice Address - Street 1:1501 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621
Practice Address - Country:US
Practice Address - Phone:864-716-0063
Practice Address - Fax:864-716-0073
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2019-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA673363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC196109OtherMEDCOST
SCP00140954OtherRAILROAD MEDICARE
SC02419AMedicaid
SCAA4567Medicare UPIN
SC02419AMedicaid