Provider Demographics
NPI:1437528957
Name:CARMODY, MARC BRYAN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:BRYAN
Last Name:CARMODY
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 1:410 CELEBRATION PL STE 302
Mailing Address - Street 2:
Mailing Address - City:CELEBRATION
Mailing Address - State:FL
Mailing Address - Zip Code:34747-5435
Mailing Address - Country:US
Mailing Address - Phone:407-303-3824
Mailing Address - Fax:407-303-3825
Practice Address - Street 1:410 CELEBRATION PL STE 302
Practice Address - Street 2:
Practice Address - City:CELEBRATION
Practice Address - State:FL
Practice Address - Zip Code:34747-5435
Practice Address - Country:US
Practice Address - Phone:407-303-3824
Practice Address - Fax:407-303-3825
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108980363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical