Basic Information
| Provider Information | |||||||||
| NPI: | 1740209469 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARROLL | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | EARL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA, APNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1383 SKYLINE DRIVE | ||||||||
| Address2: | |||||||||
| City: | WINONA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559875475 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152848924 | ||||||||
| FaxNumber: | 7152847166 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 W ADAMS ST | ||||||||
| Address2: | C/O ANESTHESIA DEPARTMENT | ||||||||
| City: | BLACK RIVER FALLS | ||||||||
| State: | WI | ||||||||
| PostalCode: | 546159108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7152845361 | ||||||||
| FaxNumber: | 7152847166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 367500000X | 66410 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | R085903 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 29802 | 01 | AANA CERTIFICATION NUMBER | OTHER | 43376100 | 05 | WI | MEDICAID | R085903 | 01 | MN | RN LICENSE NUMBER | OTHER | 0005 | 01 | WI | SEQUENCE NUMBER | OTHER | 66410 | 01 | WI | RN LICENSE NUMBER | OTHER | 1161 | 01 | WI | APNP | OTHER |