Provider Demographics
NPI:1386672491
Name:NASRALLA, CAROLE (MD)
Entity Type:Individual
Prefix:MRS
First Name:CAROLE
Middle Name:
Last Name:NASRALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 B TALISMAN DR.
Mailing Address - Street 2:#3
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147
Mailing Address - Country:US
Mailing Address - Phone:970-731-5252
Mailing Address - Fax:970-731-9922
Practice Address - Street 1:27 B TALISMAN DR.
Practice Address - Street 2:#3
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147
Practice Address - Country:US
Practice Address - Phone:970-731-5252
Practice Address - Fax:970-731-9922
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40509207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM000N5453OtherPROVIDER MEDICAID NUMBER
NM8HBL75OtherMEDICARE NUMBER
NM000K3526Medicaid
NMHSZ196OtherMEDICARE PART B
CO61453251Medicaid
COCOA106189Medicare PIN
H82899Medicare UPIN
NM000K3526Medicaid
CO370805YWQ5Medicare PIN