Basic Information
| Provider Information | |||||||||
| NPI: | 1932186434 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE INDEPENDENCE POINTE | ||||||||
| Address2: | SUITE 212 | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8647976044 | ||||||||
| FaxNumber: | 8647976198 | ||||||||
| Practice Location | |||||||||
| Address1: | 877 W FARIS RD | ||||||||
| Address2: | STE B | ||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296055608 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644556900 | ||||||||
| FaxNumber: | 8642555619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2005 | ||||||||
| LastUpdateDate: | 03/20/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 685 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0065PA | 05 | SC | MEDICAID |