Provider Demographics
NPI:1093766164
Name:CARROLL, BRIAN M (CRNA)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:M
Last Name:CARROLL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 BLANCHARD HTS
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:NY
Mailing Address - Zip Code:13073-1220
Mailing Address - Country:US
Mailing Address - Phone:607-898-5269
Mailing Address - Fax:
Practice Address - Street 1:1144 N ROAD ST
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-3353
Practice Address - Country:US
Practice Address - Phone:252-335-0531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC198874367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8000308Medicaid
NC2608879Medicare PIN