Provider Demographics
NPI:1750109260
Name:BASSIE, BRAXTON
Entity type:Individual
Prefix:
First Name:BRAXTON
Middle Name:
Last Name:BASSIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BRAXTON
Other - Middle Name:WILLIAM
Other - Last Name:BASSIE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CAA
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:7 INDEPENDENCE PT STE 300
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-4569
Practice Address - Country:US
Practice Address - Phone:864-522-3700
Practice Address - Fax:864-522-3705
Is Sole Proprietor?:No
Enumeration Date:2024-10-02
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
367H00000X
SC132367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant