Provider Demographics
NPI:1689966012
Name:CARR, STEPHEN C (PA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:C
Last Name:CARR
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 1:100 BREWSTER BLVD
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2538
Mailing Address - Country:US
Mailing Address - Phone:910-450-3346
Mailing Address - Fax:910-450-3345
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2538
Practice Address - Country:US
Practice Address - Phone:910-450-3218
Practice Address - Fax:910-450-3346
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-04
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200439363A00000X
NC0010-04726363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA5F942PE77Medicare PIN
LA$$$$$$$$$0OtherBLUE CROSS BLUE SHIELD OF LOUISIANA
LA721381266003OtherHUMANA MILITARY/TRICARE
LA2145941Medicaid