Provider Demographics
NPI:1083955660
Name:CARROLL, KATHERINE ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:ANN
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 HICKSVILLE RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-5819
Mailing Address - Country:US
Mailing Address - Phone:516-799-7500
Mailing Address - Fax:516-799-2075
Practice Address - Street 1:20 HICKSVILLE RD
Practice Address - Street 2:SUITE 2
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5819
Practice Address - Country:US
Practice Address - Phone:516-799-7500
Practice Address - Fax:516-799-2075
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009545-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant