Basic Information
| Provider Information | |||||||||
| NPI: | 1619251519 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRODIE | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | DANIELSON | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 525 VERDAE BLVD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296074021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8646035600 | ||||||||
| FaxNumber: | 8646035601 | ||||||||
| Practice Location | |||||||||
| Address1: | 9 HAWTHORNE PARK CT | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29615 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8646035600 | ||||||||
| FaxNumber: | 8646035601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2011 | ||||||||
| LastUpdateDate: | 06/14/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1693 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1274PA | 05 | SC | MEDICAID |