Healthcare Provider Details

I. General information

NPI: 1942490610
Provider Name (Legal Business Name): LEE GORDON CARROLL CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 10/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6701 N CHARLES ST
TOWSON MD
21204-6808
US

IV. Provider business mailing address

110 WEST RD STE 210
TOWSON MD
21204-2341
US

V. Phone/Fax

Practice location:
  • Phone: 410-296-4616
  • Fax: 410-337-5068
Mailing address:
  • Phone: 410-296-4616
  • Fax: 410-337-5068

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR144380
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: