Provider Demographics
NPI:1033275631
Name:BOOTH, CAROLYN M (PA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:BOOTH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6000 BOND AVE
Mailing Address - Street 2:
Mailing Address - City:EAST SAINT LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62207-2328
Mailing Address - Country:US
Mailing Address - Phone:618-332-2740
Mailing Address - Fax:618-332-8755
Practice Address - Street 1:6000 BOND AVE
Practice Address - Street 2:
Practice Address - City:EAST SAINT LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62207-2328
Practice Address - Country:US
Practice Address - Phone:618-332-2740
Practice Address - Fax:618-332-8755
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant