Provider Demographics
NPI:1902446248
Name:CARROLL, TIMOTHY MARTIN (AGACNP-BC)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:MARTIN
Last Name:CARROLL
Suffix:
Gender:M
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 STATE ST FL 4
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16507-1427
Mailing Address - Country:US
Mailing Address - Phone:814-877-5330
Mailing Address - Fax:814-877-5331
Practice Address - Street 1:300 STATE ST FL 4
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16507-1427
Practice Address - Country:US
Practice Address - Phone:814-877-5330
Practice Address - Fax:814-877-5331
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP021146363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care