Provider Demographics
NPI:1528079183
Name:HARRISON, CHARLES BRADLEY (PA-C)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:BRADLEY
Last Name:HARRISON
Suffix:
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 1:1330 BOILING SPRINGS RD
Mailing Address - Street 2:SUITE 1600
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29303
Mailing Address - Country:US
Mailing Address - Phone:864-582-6396
Mailing Address - Fax:864-582-1608
Practice Address - Street 1:1330 BOILING SPRINGS RD
Practice Address - Street 2:SUITE 1600
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303
Practice Address - Country:US
Practice Address - Phone:864-582-6396
Practice Address - Fax:864-582-1608
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2014-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1028363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0408PAMedicaid
SC0408PAMedicaid
SCP980731223Medicare PIN