Provider Demographics
NPI:1790738086
Name:HARBISON, BRIAN A (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:A
Last Name:HARBISON
Suffix:
Gender:M
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 1218
Mailing Address - Street 2:
Mailing Address - City:WINNSBORO
Mailing Address - State:SC
Mailing Address - Zip Code:29180-5218
Mailing Address - Country:US
Mailing Address - Phone:843-754-1195
Mailing Address - Fax:
Practice Address - Street 1:311 CLUB COLONY CIRCLE
Practice Address - Street 2:
Practice Address - City:BLYTHEWOOD
Practice Address - State:SC
Practice Address - Zip Code:29016-8282
Practice Address - Country:US
Practice Address - Phone:843-788-5916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA594363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCA594OtherSTATE LICENSE #
SC7800Medicare PIN