Provider Demographics
NPI:1275229494
Name:CARROLL, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
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 1:710 CREEKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:IA
Mailing Address - Zip Code:52340-8406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:221 NE GLEN OAK AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61636-1009
Practice Address - Country:US
Practice Address - Phone:309-645-8759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL209032505367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program