Provider Demographics
NPI:1265066963
Name:CAROLAN, BENJAMIN ROBERT JOHN (PA-C)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:ROBERT JOHN
Last Name:CAROLAN
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 1:2885 E LONG LAKE RD STE AB
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48085-4100
Mailing Address - Country:US
Mailing Address - Phone:586-977-7246
Mailing Address - Fax:
Practice Address - Street 1:2885 E LONG LAKE RD STE AB
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48085-4100
Practice Address - Country:US
Practice Address - Phone:586-977-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601010043363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant