Provider Demographics
NPI:1659820835
Name:BRANDENBURG, ERIC LANCE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:LANCE
Last Name:BRANDENBURG
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:
Mailing Address - Fax:
Practice Address - Street 1:905 VERDAE BLVD STE 101
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-4098
Practice Address - Country:US
Practice Address - Phone:864-286-7550
Practice Address - Fax:864-286-7551
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-28
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY020218363A00000X
SC4258363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6063PAMedicaid