Provider Demographics
NPI:1174701684
Name:CARROLL, EMILY LUISA (PA-C)
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:LUISA
Last Name:CARROLL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:LUISA
Other - Last Name:LOPEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1323 ATLANTA AVE SW
Mailing Address - Street 2:
Mailing Address - City:CULLMAN
Mailing Address - State:AL
Mailing Address - Zip Code:35055-4918
Mailing Address - Country:US
Mailing Address - Phone:256-727-3098
Mailing Address - Fax:
Practice Address - Street 1:3400 HIGHWAY 78 E
Practice Address - Street 2:
Practice Address - City:JASPER
Practice Address - State:AL
Practice Address - Zip Code:35501-8956
Practice Address - Country:US
Practice Address - Phone:205-387-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-06
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 363A00000X
ALPA.2320363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL330000025Medicaid