Provider Demographics
NPI:1649424896
Name:EISON, DANIELLE MAKUPSON (PA-C)
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MAKUPSON
Last Name:EISON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:DANIELLE
Other - Middle Name:
Other - Last Name:MAKUPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6400
Mailing Address - Fax:864-797-6198
Practice Address - Street 1:701 GROVE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29605-4210
Practice Address - Country:US
Practice Address - Phone:864-455-6540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-13
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1375363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0766PAMedicaid
SCAA5232Medicare UPIN