Provider Demographics
NPI:1316989981
Name:CARROLL, EVERETT L (APA-C)
Entity type:Individual
Prefix:
First Name:EVERETT
Middle Name:L
Last Name:CARROLL
Suffix:
Gender:M
Credentials:APA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 77150
Mailing Address - Street 2:TANANA HEALTH CLINIC
Mailing Address - City:TANANA
Mailing Address - State:AK
Mailing Address - Zip Code:99777-0150
Mailing Address - Country:US
Mailing Address - Phone:907-366-1016
Mailing Address - Fax:
Practice Address - Street 1:101 FIRST AVE
Practice Address - Street 2:TANANA HEALTH CLINIC
Practice Address - City:TANANA
Practice Address - State:AK
Practice Address - Zip Code:99777-0150
Practice Address - Country:US
Practice Address - Phone:907-366-1016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-11
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1122363A00000X
TN1287363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3663844Medicare ID - Type Unspecified