Provider Demographics
NPI:1336723840
Name:BLACK, CARL JR (PA-C)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:
Last Name:BLACK
Suffix:JR
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1216 E HUNTING PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19124-4928
Mailing Address - Country:US
Mailing Address - Phone:215-533-1333
Mailing Address - Fax:215-744-4324
Practice Address - Street 1:1216 E HUNTING PARK AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-4928
Practice Address - Country:US
Practice Address - Phone:215-533-1333
Practice Address - Fax:215-744-4324
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA005627363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical