Basic Information
| Provider Information | |||||||||
| NPI: | 1619187283 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | QUINTON | ||||||||
| MiddleName: | W | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4446 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233840614 | ||||||||
| FaxNumber: | 4239285814 | ||||||||
| Practice Location | |||||||||
| Address1: | 508 PRINCETON RD | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376012060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233840614 | ||||||||
| FaxNumber: | 4239285814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 05/05/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WC1500X | 153426 | TN | N | Nursing Service Providers | Registered Nurse | Community Health | 363LF0000X | 14954 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP2300X | 14954 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 1519749 | 05 | TN | MEDICAID |