Provider Demographics
NPI:1336193622
Name:ELMBORG, CAROLYN (CRNA)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:ELMBORG
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5752 RIDGE TRL
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-9506
Mailing Address - Country:US
Mailing Address - Phone:417-437-0357
Mailing Address - Fax:417-624-5741
Practice Address - Street 1:5752 RIDGE TRL
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-9506
Practice Address - Country:US
Practice Address - Phone:417-437-0357
Practice Address - Fax:417-624-5741
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO056659367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO913006409Medicaid
OK100788290AMedicaid
430027953OtherRR MEDICARE
KS100254890AMedicaid
OK100788290AMedicaid