Provider Demographics
NPI:1891998753
Name:CAROSELLA, NOEL C (PAC)
Entity Type:Individual
Prefix:
First Name:NOEL
Middle Name:C
Last Name:CAROSELLA
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:PO BOX 642117
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68164-8117
Mailing Address - Country:US
Mailing Address - Phone:402-398-6254
Mailing Address - Fax:402-829-8513
Practice Address - Street 1:8248 S 96TH ST
Practice Address - Street 2:
Practice Address - City:LA VISTA
Practice Address - State:NE
Practice Address - Zip Code:68128-3126
Practice Address - Country:US
Practice Address - Phone:402-398-6254
Practice Address - Fax:402-829-8513
Is Sole Proprietor?:No
Enumeration Date:2007-06-07
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1070363AM0700X
NE1732363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE099928056Medicare PIN
NE098684488Medicare PIN
IA414530099Medicare PIN