Provider Demographics
NPI:1205389335
Name:CARROLL, CHRISTOPHER SHANE (NP-C)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:SHANE
Last Name:CARROLL
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 WREN ST
Mailing Address - Street 2:
Mailing Address - City:BARNWELL
Mailing Address - State:SC
Mailing Address - Zip Code:29812-1529
Mailing Address - Country:US
Mailing Address - Phone:803-259-5762
Mailing Address - Fax:803-259-3250
Practice Address - Street 1:10706 MARLBORO AVE.
Practice Address - Street 2:
Practice Address - City:BARNWELL
Practice Address - State:SC
Practice Address - Zip Code:29812-2516
Practice Address - Country:US
Practice Address - Phone:803-259-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-25
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC20366363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20366OtherMEDICAL LICENSE
SCNP4003Medicaid