Provider Demographics
NPI:1619251519
Name:BRODIE, AMANDA DANIELSON (PA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:DANIELSON
Last Name:BRODIE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 VERDAE BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-4021
Mailing Address - Country:US
Mailing Address - Phone:864-603-5600
Mailing Address - Fax:864-603-5601
Practice Address - Street 1:9 HAWTHORNE PARK CT
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615
Practice Address - Country:US
Practice Address - Phone:864-603-5600
Practice Address - Fax:864-603-5601
Is Sole Proprietor?:No
Enumeration Date:2011-10-11
Last Update Date:2018-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1693363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1274PAMedicaid
SC1274PAMedicaid