Provider Demographics
NPI:1568828432
Name:PROVENCHER, ERRYN C (PA-C)
Entity Type:Individual
Prefix:
First Name:ERRYN
Middle Name:C
Last Name:PROVENCHER
Suffix:
Gender:F
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 1:674 W LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150-4882
Mailing Address - Country:US
Mailing Address - Phone:803-773-5227
Mailing Address - Fax:803-757-4010
Practice Address - Street 1:674 W LIBERTY ST
Practice Address - Street 2:
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4882
Practice Address - Country:US
Practice Address - Phone:803-773-5227
Practice Address - Fax:803-757-4010
Is Sole Proprietor?:No
Enumeration Date:2016-01-08
Last Update Date:2023-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK2610OtherLICENSE