Provider Demographics
NPI:1730468778
Name:CARROLL, JEFFREY RYAN (AA - C)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:RYAN
Last Name:CARROLL
Suffix:
Gender:M
Credentials:AA - C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30923 BRIDGEGATE DR
Mailing Address - Street 2:
Mailing Address - City:WESLEY CHAPEL
Mailing Address - State:FL
Mailing Address - Zip Code:33545-8214
Mailing Address - Country:US
Mailing Address - Phone:614-271-5814
Mailing Address - Fax:
Practice Address - Street 1:5424 GRAND BLVD
Practice Address - Street 2:
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-4008
Practice Address - Country:US
Practice Address - Phone:727-845-1736
Practice Address - Fax:727-849-0759
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-09
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant