Provider Demographics
NPI:1235997784
Name:BREWER, BENJAMIN WILLIAM (PA-C)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:WILLIAM
Last Name:BREWER
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 1:3815 FABER PLACE DR
Mailing Address - Street 2:
Mailing Address - City:N CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29405-8533
Mailing Address - Country:US
Mailing Address - Phone:843-767-9312
Mailing Address - Fax:843-767-9313
Practice Address - Street 1:3815 FABER PLACE DR
Practice Address - Street 2:
Practice Address - City:N CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29405-8533
Practice Address - Country:US
Practice Address - Phone:843-767-9312
Practice Address - Fax:843-767-9313
Is Sole Proprietor?:No
Enumeration Date:2024-03-11
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5249363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC6948PAMedicaid