Provider Demographics
NPI:1639712482
Name:STARR, BRIANNA JULIA
Entity Type:Individual
Prefix:
First Name:BRIANNA
Middle Name:JULIA
Last Name:STARR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1403 E GREENVILLE ST STE C
Mailing Address - Street 2:
Mailing Address - City:ANDERSON
Mailing Address - State:SC
Mailing Address - Zip Code:29621-2285
Mailing Address - Country:US
Mailing Address - Phone:864-540-8025
Mailing Address - Fax:864-540-8027
Practice Address - Street 1:1403 E GREENVILLE ST STE B
Practice Address - Street 2:
Practice Address - City:ANDERSON
Practice Address - State:SC
Practice Address - Zip Code:29621-2285
Practice Address - Country:US
Practice Address - Phone:864-540-8025
Practice Address - Fax:864-540-8027
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-24
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
SC3597363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC4321PAMedicaid