Healthcare Provider Details

I. General information

NPI: 1114938768
Provider Name (Legal Business Name): WILLIAM SEAN IRVIN PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2006
Last Update Date: 01/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 JOHN ST SUITE 201
EASLEY SC
29640-1472
US

IV. Provider business mailing address

PO BOX 2089
EASLEY SC
29641-2089
US

V. Phone/Fax

Practice location:
  • Phone: 864-850-2663
  • Fax: 864-306-0012
Mailing address:
  • Phone: 864-850-2663
  • Fax: 864-855-9577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number153
License Number StateSC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0335PA
Identifier TypeMEDICAID
Identifier StateSC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: