Provider Demographics
NPI:1942490610
Name:CARROLL, LEE GORDON (CRNA)
Entity Type:Individual
Prefix:MR
First Name:LEE
Middle Name:GORDON
Last Name:CARROLL
Suffix:
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 1:110 WEST RD STE 210
Mailing Address - Street 2:
Mailing Address - City:TOWSON
Mailing Address - State:MD
Mailing Address - Zip Code:21204-2341
Mailing Address - Country:US
Mailing Address - Phone:410-296-4616
Mailing Address - Fax:410-337-5068
Practice Address - Street 1:6701 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-6808
Practice Address - Country:US
Practice Address - Phone:410-296-4616
Practice Address - Fax:410-337-5068
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR144380367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
R144380OtherSTATE LICENCE
R144380OtherSTATE LICENCE