Provider Demographics
NPI:1902088867
Name:BROOME, AMANDA FALLS (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:FALLS
Last Name:BROOME
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:AMANDA
Other - Middle Name:LEE
Other - Last Name:FALLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:958 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-2148
Mailing Address - Country:US
Mailing Address - Phone:864-425-1572
Mailing Address - Fax:864-469-7422
Practice Address - Street 1:958 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-2148
Practice Address - Country:US
Practice Address - Phone:864-425-1572
Practice Address - Fax:864-469-7422
Is Sole Proprietor?:No
Enumeration Date:2007-12-03
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL1258363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAA6221C020Medicare PIN
SCAA6221Medicare UPIN