Healthcare Provider Details

I. General information

NPI: 1114400611
Provider Name (Legal Business Name): JORDAN DAVID CARR PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 09/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

278 VT 149
WEST PAWLET VT
05775-9798
US

IV. Provider business mailing address

183 FITZGERALD RD
MIDDLETOWN SPRINGS VT
05757-4119
US

V. Phone/Fax

Practice location:
  • Phone: 802-645-0580
  • Fax:
Mailing address:
  • Phone: 802-558-7466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number055.0031401
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: