Provider Demographics
NPI:1326002452
Name:CARR, JERAL W (PA-C)
Entity Type:Individual
Prefix:
First Name:JERAL
Middle Name:W
Last Name:CARR
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 1:1289 SW STATE ROAD 47
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-0484
Mailing Address - Country:US
Mailing Address - Phone:386-755-0421
Mailing Address - Fax:386-487-1234
Practice Address - Street 1:1289 SW STATE ROAD 47
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0484
Practice Address - Country:US
Practice Address - Phone:386-755-0421
Practice Address - Fax:386-487-1234
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2009-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9102567363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLPA9102567OtherMEDICAL LICENSE #
FL363A00000XOtherTAXONOMY CODE
FLPA9102567OtherMEDICAL LICENSE #
FLQ36889Medicare UPIN