Provider Demographics
NPI:1053613786
Name:OBENZA, BRIAN R (PA-C)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:R
Last Name:OBENZA
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 1:180 WINGO WAY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-1810
Mailing Address - Country:US
Mailing Address - Phone:843-534-1770
Mailing Address - Fax:843-534-1767
Practice Address - Street 1:180 WINGO WAY
Practice Address - Street 2:SUITE 204
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-1810
Practice Address - Country:US
Practice Address - Phone:843-534-1770
Practice Address - Fax:843-534-1767
Is Sole Proprietor?:No
Enumeration Date:2010-12-01
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SCTL1599363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical