Healthcare Provider Details

I. General information

NPI: 1649428277
Provider Name (Legal Business Name): DOUGLAS JOHN CARROLL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2008
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 SUSANNAH ST
JOHNSON CITY TN
37601-1748
US

IV. Provider business mailing address

2410 SUSANNAH ST
JOHNSON CITY TN
37601-1748
US

V. Phone/Fax

Practice location:
  • Phone: 423-282-9011
  • Fax:
Mailing address:
  • Phone: 423-282-9011
  • Fax: 704-639-0785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3434
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-01521
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number3434
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number3434
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: