Provider Demographics
NPI:1629039847
Name:CRAFTON, CHARLES J (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:J
Last Name:CRAFTON
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 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:14 RICHLAND MEDICAL PARK DR STE 350
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6896
Practice Address - Country:US
Practice Address - Phone:803-434-1663
Practice Address - Fax:803-434-3894
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.002054363A00000X
OH50-002054363AS0400X
SCPA1989363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1724PAMedicaid
KY95003851Medicaid
KY95003851Medicaid
SC1724PAMedicaid
SCPA19661955Medicare PIN