Healthcare Provider Details

I. General information

NPI: 1316708092
Provider Name (Legal Business Name): RORY CARROLL AGPCNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2024
Last Update Date: 05/22/2024
Certification Date: 05/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 BRADHURST AVE STE 3060N
HAWTHORNE NY
10532-2180
US

IV. Provider business mailing address

250 S CENTRAL AVE APT 5H
HARTSDALE NY
10530-3175
US

V. Phone/Fax

Practice location:
  • Phone: 914-372-7887
  • Fax: 914-372-7884
Mailing address:
  • Phone: 518-605-0001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number311495
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: