Provider Demographics
NPI:1861945693
Name:CARBERRY, MAUREEN (PA)
Entity type:Individual
Prefix:
First Name:MAUREEN
Middle Name:
Last Name:CARBERRY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3999 DUTCHMANS LN STE 2E
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4748
Practice Address - Country:US
Practice Address - Phone:502-559-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
OH50.006551RX363A00000X
KYPA3183363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant