Provider Demographics
NPI:1356472559
Name:ADDY, CAROL A (PA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:A
Last Name:ADDY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 TROPHY CLUB DR
Mailing Address - Street 2:
Mailing Address - City:TROPHY CLUB
Mailing Address - State:TX
Mailing Address - Zip Code:76262-5580
Mailing Address - Country:US
Mailing Address - Phone:817-430-9111
Mailing Address - Fax:817-430-8911
Practice Address - Street 1:945 TROPHY CLUB DR
Practice Address - Street 2:
Practice Address - City:TROPHY CLUB
Practice Address - State:TX
Practice Address - Zip Code:76262-5580
Practice Address - Country:US
Practice Address - Phone:817-430-9111
Practice Address - Fax:817-430-8911
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00527363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXR0131625OtherTEXAS DPS
TXPA00527OtherTEXAS MEDICAL BOARD LICEN
TXPA00527OtherTEXAS MEDICAL BOARD LICEN
TX8K3655Medicare PIN
TX8K3654Medicare PIN
TX8K8862Medicare PIN