Basic Information
| Provider Information | |||||||||
| NPI: | 1013115237 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IRVIN | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1524 EUBANK BLVD NE SUITE 6 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871144908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055038806 | ||||||||
| FaxNumber: | 8885038511 | ||||||||
| Practice Location | |||||||||
| Address1: | 1524 EUBANK BLVD NE STE 6 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871124160 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5055038806 | ||||||||
| FaxNumber: | 8885038511 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2007 | ||||||||
| LastUpdateDate: | 06/16/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | PA2004-0015 | NM | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 97175323 | 05 | NM | MEDICAID |