Basic Information
| Provider Information | |||||||||
| NPI: | 1346595014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 S GERMANTOWN RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381382205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017593100 | ||||||||
| FaxNumber: | 9017593196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 S GERMANTOWN RD | ||||||||
| Address2: | |||||||||
| City: | GERMANTOWN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381382205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017593100 | ||||||||
| FaxNumber: | 9017593196 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2012 | ||||||||
| LastUpdateDate: | 10/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MPA.1778.TL | SC | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA180137 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA00386 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 3336 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 3366 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 200682 | LA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | Q031131 | 05 | TN | MEDICAID | 07004261 | 05 | MS | MEDICAID | 1102675 | 01 | NCCPA | OTHER | 2351991 | 05 | LA | MEDICAID | MPA.1778.TL | 01 | SC | SOUTH CAROLINA PA LICENSE | OTHER |