Provider Demographics
NPI:1912639683
Name:MEDLIN, CARSON BREWER (PA)
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:BREWER
Last Name:MEDLIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CARSON
Other - Middle Name:MACKENZIE IDA
Other - Last Name:BREWER
Other - Suffix:
Other - Last Name Type:Former Name
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 1:10630 CLEMSON BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SENECA
Practice Address - State:SC
Practice Address - Zip Code:29678-4545
Practice Address - Country:US
Practice Address - Phone:864-482-6000
Practice Address - Fax:864-482-7000
Is Sole Proprietor?:No
Enumeration Date:2022-06-30
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363AS0400X
SC4497363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPENDINGMedicaid