1245228501 NPI number — MRS. KARA DARLENE CARPENTER PA C

Table of content: MRS. KARA DARLENE CARPENTER PA C (NPI 1245228501)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245228501 NPI number — MRS. KARA DARLENE CARPENTER PA C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARPENTER
Provider First Name:
KARA
Provider Middle Name:
DARLENE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PA C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRYAN
Provider Other First Name:
KARA
Provider Other Middle Name:
DARLENE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1245228501
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/15/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 ALEX LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLESTON
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25304-2952
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-734-2040
Provider Business Mailing Address Fax Number:
304-734-2047

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
303 OHIO AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLESTON
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25302-2212
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
681-205-8701
Provider Business Practice Location Address Fax Number:
681-208-8702
Provider Enumeration Date:
10/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  01058 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AM0700X , with the licence number: 01058 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 001720818 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 1069109 . This is a "WV DWC" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 7100274210 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0107132 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1245228501 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".




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