Provider Demographics
NPI:1669145249
Name:BENNETT, BRALYN JR (PA-C)
Entity type:Individual
Prefix:MR
First Name:BRALYN
Middle Name:
Last Name:BENNETT
Suffix:JR
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 1:8170 ROURK ST STE 100
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-4127
Mailing Address - Country:US
Mailing Address - Phone:843-449-0453
Mailing Address - Fax:
Practice Address - Street 1:5046 HIGHWAY 17 BYP S STE 200
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29588-4503
Practice Address - Country:US
Practice Address - Phone:843-839-3501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3837363A00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant