Provider Demographics
NPI:1821024662
Name:ECCLES, JOSIEANN MAURO (PA)
Entity Type:Individual
Prefix:
First Name:JOSIEANN
Middle Name:MAURO
Last Name:ECCLES
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:PO BOX 3066
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-3066
Mailing Address - Country:US
Mailing Address - Phone:843-757-9838
Mailing Address - Fax:843-757-9667
Practice Address - Street 1:1714 TICKTON HALL RD
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-7719
Practice Address - Country:US
Practice Address - Phone:843-757-9838
Practice Address - Fax:843-757-9667
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCA933363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCR56881Medicare UPIN