Basic Information
Provider Information | |||||||||
NPI: | 1184659674 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SUN | ||||||||
FirstName: | CARRIE | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 800 N 5TH AVE | ||||||||
Address2: |   | ||||||||
City: | SEQUIM | ||||||||
State: | WA | ||||||||
PostalCode: | 983823045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3605650999 | ||||||||
FaxNumber: | 3605824221 | ||||||||
Practice Location | |||||||||
Address1: | 800 N 5TH AVE | ||||||||
Address2: |   | ||||||||
City: | SEQUIM | ||||||||
State: | WA | ||||||||
PostalCode: | 983823045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3605650999 | ||||||||
FaxNumber: | 3605824221 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/12/2006 | ||||||||
LastUpdateDate: | 11/12/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/12/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | D0062604 | MD | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD00046290 | WA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | MD444615 | PA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 250470 | 01 | IN | MEDICARE GROUP | OTHER | 000000544173 | 01 | IN | ANTHEM PIN | OTHER | 200859330C | 01 | IN | MEDICAID GROUP | OTHER | 103280724 | 05 | PA |   | MEDICAID | 200529610 | 05 | IN |   | MEDICAID |