Provider Demographics
NPI:1902428808
Name:CARROLL, ALYSSA BENE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:ALYSSA
Middle Name:BENE
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1001 MAIN ST STE 500A
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-2038
Mailing Address - Country:US
Mailing Address - Phone:309-672-4980
Mailing Address - Fax:309-672-2931
Practice Address - Street 1:1001 MAIN ST STE 500A
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-2038
Practice Address - Country:US
Practice Address - Phone:309-672-4980
Practice Address - Fax:309-672-2931
Is Sole Proprietor?:No
Enumeration Date:2020-05-13
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.008561363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant