Basic Information
| Provider Information | |||||||||
| NPI: | 1114938768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IRVIN | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | SEAN | ||||||||
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| Credential: | PAC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2089 | ||||||||
| Address2: | |||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296412089 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648502663 | ||||||||
| FaxNumber: | 8648559577 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 JOHN ST | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | EASLEY | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296401472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8648502663 | ||||||||
| FaxNumber: | 8643060012 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2006 | ||||||||
| LastUpdateDate: | 01/28/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 153 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 0335PA | 05 | SC | MEDICAID |