Provider Demographics
NPI:1558325357
Name:CARLYLE, JOHN GREGORY II (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:GREGORY
Last Name:CARLYLE
Suffix:II
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 1:21 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:NORTH EAST
Mailing Address - State:MD
Mailing Address - Zip Code:21901-3328
Mailing Address - Country:US
Mailing Address - Phone:443-907-3089
Mailing Address - Fax:
Practice Address - Street 1:9000 FRANKLIN SQUARE DR
Practice Address - Street 2:2 NORTH
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21237-3901
Practice Address - Country:US
Practice Address - Phone:443-777-7179
Practice Address - Fax:443-777-8242
Is Sole Proprietor?:No
Enumeration Date:2006-04-17
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR125772367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD408579500Medicaid
MD408579500Medicaid