Provider Demographics
NPI:1982616264
Name:CRISP, BRIAN C (PA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:C
Last Name:CRISP
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 3239
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29502-3239
Mailing Address - Country:US
Mailing Address - Phone:843-777-7092
Mailing Address - Fax:843-777-7102
Practice Address - Street 1:1005 E CHEVES ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2707
Practice Address - Country:US
Practice Address - Phone:843-777-7900
Practice Address - Fax:843-777-7925
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1130363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCQ70633Medicare UPIN
SCAA14498552Medicare ID - Type Unspecified