Provider Demographics
NPI:1497369284
Name:CARROLL, BRIAN (PA-C)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CARROLL
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 1:12903 LONGBOAT WAY
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-3829
Mailing Address - Country:US
Mailing Address - Phone:760-828-2196
Mailing Address - Fax:
Practice Address - Street 1:12903 LONGBOAT WAY
Practice Address - Street 2:
Practice Address - City:DEL MAR
Practice Address - State:CA
Practice Address - Zip Code:92014-3829
Practice Address - Country:US
Practice Address - Phone:760-828-2196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-31
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant