Provider Demographics
NPI:1669956538
Name:MYRICK, LISA CRESWELL (PA)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:CRESWELL
Last Name:MYRICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:DIANE
Other - Last Name:CRESWELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7182 WOODROW ST STE 200
Mailing Address - Street 2:
Mailing Address - City:IRMO
Mailing Address - State:SC
Mailing Address - Zip Code:29063-2832
Mailing Address - Country:US
Mailing Address - Phone:803-749-1111
Mailing Address - Fax:803-749-0050
Practice Address - Street 1:7182 WOODROW ST STE 200
Practice Address - Street 2:
Practice Address - City:IRMO
Practice Address - State:SC
Practice Address - Zip Code:29063-2832
Practice Address - Country:US
Practice Address - Phone:803-749-1111
Practice Address - Fax:803-749-0050
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA8943363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCMPA3202PAOtherSC PA LICENSE