Provider Demographics
NPI:1407047756
Name:CARTER, DARRELL ANTHONY (PA)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:ANTHONY
Last Name:CARTER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:777 FLOWER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91201-3015
Mailing Address - Country:US
Mailing Address - Phone:818-637-2000
Mailing Address - Fax:818-242-8761
Practice Address - Street 1:1500 W WEST COVINA PKWY
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2708
Practice Address - Country:US
Practice Address - Phone:626-856-2226
Practice Address - Fax:626-960-5284
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2011-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA10429363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC503ZMedicare PIN
CAS11572Medicare UPIN