Basic Information
| Provider Information | |||||||||
| NPI: | 1720596521 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARR | ||||||||
| FirstName: | ROBERT | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6421 CONGRESS AVE STE 113 | ||||||||
| Address2: | |||||||||
| City: | BOCA RATON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334872858 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8135717184 | ||||||||
| FaxNumber: | 8136544695 | ||||||||
| Practice Location | |||||||||
| Address1: | 12500 N DALE MABRY HWY | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336182809 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139607533 | ||||||||
| FaxNumber: | 8133555039 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2018 | ||||||||
| LastUpdateDate: | 01/04/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9110966 | FL | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA9110966 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 023768600 | 05 | FL | MEDICAID |