Provider Demographics
NPI:1346595014
Name:CARROLL, MATTHEW L (PA)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:L
Last Name:CARROLL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1400 S GERMANTOWN RD
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-2205
Mailing Address - Country:US
Mailing Address - Phone:901-759-3100
Mailing Address - Fax:901-759-3196
Practice Address - Street 1:1400 S GERMANTOWN RD
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-2205
Practice Address - Country:US
Practice Address - Phone:901-759-3100
Practice Address - Fax:901-759-3196
Is Sole Proprietor?:No
Enumeration Date:2012-07-19
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMPA.1778.TL363A00000X
ORPA180137363A00000X
MSPA00386363A00000X
TN3336363A00000X
TN3366363A00000X, 363A00000X
LA200682363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ031131Medicaid
MS07004261Medicaid
1102675OtherNCCPA
LA2351991Medicaid
SCMPA.1778.TLOtherSOUTH CAROLINA PA LICENSE