Provider Demographics
NPI:1598132961
Name:BUCHANAN, BLAINE DAVID (PA)
Entity Type:Individual
Prefix:
First Name:BLAINE
Middle Name:DAVID
Last Name:BUCHANAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:225 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3050
Practice Address - Country:US
Practice Address - Phone:864-560-4420
Practice Address - Fax:864-560-5296
Is Sole Proprietor?:No
Enumeration Date:2015-09-01
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCTL3234363AS0400X
NC0010-05930363AS0400X
SC3234363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCF5735019OtherMEDICARE PIN
SC3204PAMedicaid