Provider Demographics
NPI:1861682221
Name:CARROLL, VALERIE ANASTASIA (PAC)
Entity Type:Individual
Prefix:MS
First Name:VALERIE
Middle Name:ANASTASIA
Last Name:CARROLL
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 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3034 FISH HATCHERY RD
Practice Address - Street 2:
Practice Address - City:FITCHBURG
Practice Address - State:WI
Practice Address - Zip Code:53713-3125
Practice Address - Country:US
Practice Address - Phone:608-270-5656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-31
Last Update Date:2015-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2899363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL85003005OtherLICENSED PHYSICIAN ASSISTANT
IL1077788OtherNCCPA CERTIFICATION
IL85003005OtherSTATE LISCENSE