Healthcare Provider Details

I. General information

NPI: 1124752779
Provider Name (Legal Business Name): NATHAN MITCHELL CARROLL DNP, CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2022
Last Update Date: 07/11/2022
Certification Date: 06/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N ALLEN ST
ROBINSON IL
62454-1114
US

IV. Provider business mailing address

152 EDWARDS ST APT A
GLEN CARBON IL
62034-1132
US

V. Phone/Fax

Practice location:
  • Phone: 618-544-3131
  • Fax:
Mailing address:
  • Phone: 618-535-5194
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209025391
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: