Provider Demographics
NPI:1124752779
Name:CARROLL, NATHAN MITCHELL (DNP, CRNA)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:MITCHELL
Last Name:CARROLL
Suffix:
Gender:M
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 EDWARDS ST APT A
Mailing Address - Street 2:
Mailing Address - City:GLEN CARBON
Mailing Address - State:IL
Mailing Address - Zip Code:62034-1132
Mailing Address - Country:US
Mailing Address - Phone:618-535-5194
Mailing Address - Fax:
Practice Address - Street 1:1000 N ALLEN ST
Practice Address - Street 2:
Practice Address - City:ROBINSON
Practice Address - State:IL
Practice Address - Zip Code:62454-1114
Practice Address - Country:US
Practice Address - Phone:618-544-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-11
Last Update Date:2022-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209025391367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered