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NPI Code Detail

MEDICARE: KORI L CARROLL PA

MEDICARE: KORI L CARROLL PA
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician Assistant085001261IL

General Provider Information

NPI Number : 1598752628
Entity Type Code : Individual
Provider Name (Legal Business Name) : KORI L CARROLL PA
Provider Business Mailing Address
First Line : 611 W PARK ST
Second Line :
City : URBANA
State : IL
Zip : 61801-2529
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3105 FIELDS SOUTH DR
Second Line :
City : CHAMPAIGN
State : IL
Zip : 61822-3743
Country : US
Telephone Number : 217-902-7527
Fax Number : 217-902-7755
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/04/2005
Last Update Date : 04/23/2019

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Directions to “ KORI L CARROLL PA” Practice Location

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