Basic Information
| Provider Information | |||||||||
| NPI: | 1225015134 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CAROLLO | ||||||||
| FirstName: | LYDIA | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 197 ADAMS RD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012672930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4134588182 | ||||||||
| FaxNumber: | 4134583140 | ||||||||
| Practice Location | |||||||||
| Address1: | 197 ADAMS RD | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSTOWN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 012672930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4136645900 | ||||||||
| FaxNumber: | 4136645767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/30/2005 | ||||||||
| LastUpdateDate: | 10/07/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 24 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 9000419 | 05 | VT | MEDICAID |