Provider Demographics
NPI:1205925195
Name:CARREL, JERRY EDWARD
Entity type:Individual
Prefix:MR
First Name:JERRY
Middle Name:EDWARD
Last Name:CARREL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 NE 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MOORE
Mailing Address - State:OK
Mailing Address - Zip Code:73160-8625
Mailing Address - Country:US
Mailing Address - Phone:405-799-5951
Mailing Address - Fax:
Practice Address - Street 1:921 N.E.13TH
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73104
Practice Address - Country:US
Practice Address - Phone:405-270-0501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA519363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical