Healthcare Provider Details

I. General information

NPI: 1730590522
Provider Name (Legal Business Name): MR. CAMERON KROLL
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2014
Last Update Date: 11/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2929 FLOYD AVE APT 380
MODESTO CA
95355-8777
US

IV. Provider business mailing address

2929 FLOYD AVE APT 380
MODESTO CA
95355-8777
US

V. Phone/Fax

Practice location:
  • Phone: 775-771-2124
  • Fax:
Mailing address:
  • Phone: 775-771-2124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: