Basic Information
| Provider Information | |||||||||
| NPI: | 1043311608 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LACARBONARA | ||||||||
| FirstName: | FREDRIC | ||||||||
| MiddleName: | EMILIO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 236 | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255500236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046754340 | ||||||||
| FaxNumber: | 3046751328 | ||||||||
| Practice Location | |||||||||
| Address1: | 2520 VALLEY DR | ||||||||
| Address2: | |||||||||
| City: | PT PLEASANT | ||||||||
| State: | WV | ||||||||
| PostalCode: | 255502031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3046754340 | ||||||||
| FaxNumber: | 3046751328 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 01/27/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 15018 | WV | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 550744227 | 01 | WV | COMMERICAL INSURANCE | OTHER | 0672311 | 05 | OH | MEDICAID | 001721829 | 01 | WA | BCBS | OTHER | 0101673000 | 05 | WV | MEDICAID |