Healthcare Provider Details

I. General information

NPI: 1891160016
Provider Name (Legal Business Name): ANTHONY TY MEDLIN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 E WOOD ST
SPARTANBURG SC
29303-3020
US

IV. Provider business mailing address

PO BOX 743070
ATLANTA GA
30374-3070
US

V. Phone/Fax

Practice location:
  • Phone: 864-208-8800
  • Fax: 864-208-8657
Mailing address:
  • Phone: 864-560-4304
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2494
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: