Provider Demographics
NPI:1841284270
Name:CARROLL, JANINE M (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:JANINE
Middle Name:M
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:332 DEWEY STREET
Mailing Address - Street 2:TACONIC ORTHOPEDICS PC
Mailing Address - City:BENNINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05201
Mailing Address - Country:US
Mailing Address - Phone:802-442-6314
Mailing Address - Fax:802-447-1686
Practice Address - Street 1:332 DEWEY STREET
Practice Address - Street 2:TACONIC ORTHOPEDICS PC
Practice Address - City:BENNINGTON
Practice Address - State:VT
Practice Address - Zip Code:05201
Practice Address - Country:US
Practice Address - Phone:802-442-6314
Practice Address - Fax:802-447-1686
Is Sole Proprietor?:No
Enumeration Date:2005-08-31
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0550030203363A00000X
VT055-0030203363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0005117Medicaid
VT635529OtherMVP
VT9000271Medicaid
VT200010961OtherRAILROAD MEDICARE/ PALMETTO
VTGRTH18953OtherBC/BS
VTGRTH18953OtherBC/BS
VTS26572Medicare UPIN