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General NPI Number Information
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NPI Number | 1417449810
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Entity Type | Individual
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Provider Name | BRIAN CARROLL
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Gender | Male
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Dates
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Enumeration Date | 05/31/2018
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Last Update Date | 10/31/2024
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Provider Practice Location Address
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Address Line | 8552 N GOVERNMENT WAY
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City | HAYDEN
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State | ID
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Zip | 83835-9280
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Country | US
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Telephone | 208-772-7600
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Fax |
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Provider Business Mailing Address
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Address Line | 8552 N GOVERNMENT WAY
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City | HAYDEN
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State | ID
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Zip | 83835-9280
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Country | US
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Telephone | 208-772-7600
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163WS0200X
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Taxonomy Name | School Registered Nurse
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License Number | RN60272088
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License Number State | WA
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | AP60872413
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License Number State | WA
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Taxonomy #3
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 57988
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License Number State | ID
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