Basic Information
| Provider Information | |||||||||
| NPI: | 1669956538 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MYRICK | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | CRESWELL | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CRESWELL | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | DIANE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7182 WOODROW ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | IRMO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290632832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037491111 | ||||||||
| FaxNumber: | 8037490050 | ||||||||
| Practice Location | |||||||||
| Address1: | 7182 WOODROW ST STE 200 | ||||||||
| Address2: | |||||||||
| City: | IRMO | ||||||||
| State: | SC | ||||||||
| PostalCode: | 290632832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8037491111 | ||||||||
| FaxNumber: | 8037490050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2018 | ||||||||
| LastUpdateDate: | 09/30/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | 8943 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | MPA3202PA | 01 | SC | SC PA LICENSE | OTHER |