Provider Demographics
NPI:1790012151
Name:BRITTSAN, CAROL LYNNE (PA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LYNNE
Last Name:BRITTSAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751649
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1649
Mailing Address - Country:US
Mailing Address - Phone:843-789-1620
Mailing Address - Fax:843-724-2454
Practice Address - Street 1:3508 S LIVE OAK DR
Practice Address - Street 2:
Practice Address - City:MONCKS CORNER
Practice Address - State:SC
Practice Address - Zip Code:29461-8737
Practice Address - Country:US
Practice Address - Phone:843-958-2590
Practice Address - Fax:843-606-7996
Is Sole Proprietor?:No
Enumeration Date:2009-11-05
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1414363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1209PAMedicaid