MEDICARE: SHERIDAN CARROLL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant	50.009055RX	OH

General Provider Information

NPI Number	:	1447005392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHERIDAN CARROLL

Provider Business Mailing Address
First Line	:	11100 STATE ROUTE 41
Second Line	:
City	:	WEST UNION
State	:	OH
Zip	:	45693-8806
Country	:	US
Telephone Number	:	937-550-3657
Fax Number	:

Provider Business Practice Location Address
First Line	:	11100 STATE ROUTE 41
Second Line	:
City	:	WEST UNION
State	:	OH
Zip	:	45693-8806
Country	:	US
Telephone Number	:	937-550-3657
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2024
Last Update Date	:	03/25/2025

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Directions to “ SHERIDAN CARROLL ” Practice Location

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