Provider Demographics
NPI:1417449810
Name:CARROLL, BRIAN
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8552 N GOVERNMENT WAY
Mailing Address - Street 2:
Mailing Address - City:HAYDEN
Mailing Address - State:ID
Mailing Address - Zip Code:83835-9280
Mailing Address - Country:US
Mailing Address - Phone:208-772-7600
Mailing Address - Fax:
Practice Address - Street 1:8552 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:HAYDEN
Practice Address - State:ID
Practice Address - Zip Code:83835-9280
Practice Address - Country:US
Practice Address - Phone:208-772-7600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60272088163WS0200X
WAAP60872413367500000X
ID57988367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163WS0200XNursing Service ProvidersRegistered NurseSchool