Provider Demographics
NPI:1881318632
Name:CARROLL, GREGORY (RN, BSN)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3833 S BOND AVE APT 118
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4740
Mailing Address - Country:US
Mailing Address - Phone:815-405-8044
Mailing Address - Fax:
Practice Address - Street 1:3455 SW US VETERANS HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3076
Practice Address - Country:US
Practice Address - Phone:815-405-8044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202202369RN163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine