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General NPI Number Information
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NPI Number | 1508914904
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Entity Type | Individual
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Provider Name | MARY L CAROLLO P A C
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Gender | Female
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Dates
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Enumeration Date | 01/08/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 175 S UNION BLVD STE 345
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City | COLORADO SPRINGS
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State | CO
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Zip | 80910
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Country | US
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Telephone | 719-471-7158
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Fax | 719-471-7159
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Provider Business Mailing Address
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Address Line | 5955 WILSON ROAD
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City | COLORADO SPRINGS
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State | CO
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Zip | 80919-3553
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Country | US
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Telephone | 719-548-9182
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Fax | 719-593-1512
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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 | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 498
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License Number State | CO
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