Healthcare Provider Details

I. General information

NPI: 1760386478
Provider Name (Legal Business Name): MOIRA JANE CARROLL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2026
Last Update Date: 10/06/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CONVENTION AVE
PHILADELPHIA PA
19104-4311
US

IV. Provider business mailing address

3400 SPRUCE ST
PHILADELPHIA PA
19104-4238
US

V. Phone/Fax

Practice location:
  • Phone: 215-662-4004
  • Fax:
Mailing address:
  • Phone: 215-662-4400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA068269
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: