1740209469 NPI number — MR. JAMES EARL CARROLL CRNA, APNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740209469 NPI number — MR. JAMES EARL CARROLL CRNA, APNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARROLL
Provider First Name:
JAMES
Provider Middle Name:
EARL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CRNA, APNP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740209469
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1383 SKYLINE DRIVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINONA
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55987-5475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-284-8924
Provider Business Mailing Address Fax Number:
715-284-7166

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 W ADAMS ST
Provider Second Line Business Practice Location Address:
C/O ANESTHESIA DEPARTMENT
Provider Business Practice Location Address City Name:
BLACK RIVER FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54615-9108
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-284-5361
Provider Business Practice Location Address Fax Number:
715-284-7166
Provider Enumeration Date:
07/19/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  66410 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 367500000X , with the licence number: R085903 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 29802 . This is a "AANA CERTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".
  • Identifier: 43376100 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: R085903 . This is a "RN LICENSE NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 0005 . This is a "SEQUENCE NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 66410 . This is a "RN LICENSE NUMBER" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 1161 . This is a "APNP" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".




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