Provider Demographics
NPI:1649840208
Name:MACCARTY, PAUL CARPENTER I
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:CARPENTER
Last Name:MACCARTY
Suffix:I
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 1:4157 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-6017
Mailing Address - Country:US
Mailing Address - Phone:434-572-7908
Mailing Address - Fax:
Practice Address - Street 1:4157 RIVER RD
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-6017
Practice Address - Country:US
Practice Address - Phone:434-572-7908
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2021-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0110008116363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program