Provider Demographics
NPI:1548314693
Name:CARROLL, JOSHUA
Entity type:Individual
Prefix:
First Name:JOSHUA
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 1:28523 N 221ST AVE
Mailing Address - Street 2:
Mailing Address - City:WITTMANN
Mailing Address - State:AZ
Mailing Address - Zip Code:85361-9784
Mailing Address - Country:US
Mailing Address - Phone:602-738-8788
Mailing Address - Fax:
Practice Address - Street 1:28523 N 221ST AVE
Practice Address - Street 2:
Practice Address - City:WITTMANN
Practice Address - State:AZ
Practice Address - Zip Code:85361-9784
Practice Address - Country:US
Practice Address - Phone:602-738-8788
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10624373H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes373H00000XNursing Service Related ProvidersDay Training/Habilitation Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ976631Medicaid