Provider Demographics
NPI:1114938768
Name:IRVIN, WILLIAM SEAN (PAC)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:SEAN
Last Name:IRVIN
Suffix:
Gender:M
Credentials:PAC
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 2089
Mailing Address - Street 2:
Mailing Address - City:EASLEY
Mailing Address - State:SC
Mailing Address - Zip Code:29641-2089
Mailing Address - Country:US
Mailing Address - Phone:864-850-2663
Mailing Address - Fax:864-855-9577
Practice Address - Street 1:112 JOHN ST
Practice Address - Street 2:SUITE 201
Practice Address - City:EASLEY
Practice Address - State:SC
Practice Address - Zip Code:29640-1472
Practice Address - Country:US
Practice Address - Phone:864-850-2663
Practice Address - Fax:864-306-0012
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC153363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0335PAMedicaid
SCR29449Medicare UPIN
SC0335PAMedicaid
SCR294499362Medicare PIN
SCR294491223Medicare PIN