Healthcare Provider Details

I. General information

NPI: 1821024662
Provider Name (Legal Business Name): JOSIEANN MAURO ECCLES PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1714 TICKTON HALL RD
RIDGELAND SC
29936-7719
US

IV. Provider business mailing address

PO BOX 3066
BLUFFTON SC
29910-3066
US

V. Phone/Fax

Practice location:
  • Phone: 843-757-9838
  • Fax: 843-757-9667
Mailing address:
  • Phone: 843-757-9838
  • Fax: 843-757-9667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberA933
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: