Healthcare Provider Details

I. General information

NPI: 1386183994
Provider Name (Legal Business Name): KEITH BRANDON HASELEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2017
Last Update Date: 06/26/2025
Certification Date: 06/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 FOLLY RD
CHARLESTON SC
29412-2518
US

IV. Provider business mailing address

PO BOX 751649
CHARLOTTE NC
28275-1649
US

V. Phone/Fax

Practice location:
  • Phone: 843-203-2246
  • Fax: 843-203-2247
Mailing address:
  • Phone: 888-472-0043
  • Fax: 843-724-2440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number020599
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5566
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: