Provider Demographics
NPI:1093024978
Name:MCCARROLL, LISA ANN (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:ANN
Last Name:MCCARROLL
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 1:52 HOMESDALE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-3742
Mailing Address - Country:US
Mailing Address - Phone:860-621-1576
Mailing Address - Fax:
Practice Address - Street 1:28 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3654
Practice Address - Country:US
Practice Address - Phone:860-358-6572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-27
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002457363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant