Provider Demographics
NPI:1730290297
Name:KNIOLA, CAROL L (PAC)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:L
Last Name:KNIOLA
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 BOSTON ST STE J1
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-5723
Mailing Address - Country:US
Mailing Address - Phone:410-522-0001
Mailing Address - Fax:410-522-0017
Practice Address - Street 1:3500 BOSTON ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-5251
Practice Address - Country:US
Practice Address - Phone:410-522-0001
Practice Address - Fax:410-522-0017
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC01503363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP45621Medicare UPIN