Provider Demographics
NPI:1225511801
Name:CARROLL, THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
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 1:5114 OLD HICKORY BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:HERMITAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37076-2590
Mailing Address - Country:US
Mailing Address - Phone:615-850-6960
Mailing Address - Fax:615-777-3393
Practice Address - Street 1:5114 OLD HICKORY BLVD STE 201
Practice Address - Street 2:
Practice Address - City:HERMITAGE
Practice Address - State:TN
Practice Address - Zip Code:37076-2590
Practice Address - Country:US
Practice Address - Phone:615-850-6960
Practice Address - Fax:615-777-3393
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4082363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNMC5812246OtherDEA NUMBER