Healthcare Provider Details

I. General information

NPI: 1972745321
Provider Name (Legal Business Name): PAUL CARR PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 01/02/2020
Certification Date: 01/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

636 DEL PRADO BLVD S
CAPE CORAL FL
33990-2668
US

IV. Provider business mailing address

PO BOX 151368
CAPE CORAL FL
33915
US

V. Phone/Fax

Practice location:
  • Phone: 239-424-3513
  • Fax: 239-424-4039
Mailing address:
  • Phone: 239-424-3513
  • Fax: 239-424-4039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110002983
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9106423
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: