Provider Demographics
NPI:1104928191
Name:CARROLL, WILLIAM MICHAEL (PA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:MICHAEL
Last Name:CARROLL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11910 GREENVILLE AVE
Mailing Address - Street 2:SUITE 500
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75243-3596
Mailing Address - Country:US
Mailing Address - Phone:214-572-1124
Mailing Address - Fax:214-572-7724
Practice Address - Street 1:11888 MARSH LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75234-8083
Practice Address - Country:US
Practice Address - Phone:972-488-9222
Practice Address - Fax:972-488-0625
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04449363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXT84641Medicare UPIN