Provider Demographics
NPI:1962773648
Name:CARROLL, CLARK (APNP)
Entity type:Individual
Prefix:
First Name:CLARK
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:APNP
Other - Prefix:
Other - First Name:CLARK
Other - Middle Name:T
Other - Last Name:CARROLL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:203 W SUNNY LN
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53546-9091
Mailing Address - Country:US
Mailing Address - Phone:608-755-1475
Mailing Address - Fax:608-755-1733
Practice Address - Street 1:1820 CENTER AVE STE 170
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53546-2878
Practice Address - Country:US
Practice Address - Phone:608-755-1475
Practice Address - Fax:608-755-1733
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7914363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1962773648Medicaid