Basic Information
| Provider Information | |||||||||
| NPI: | 1215160460 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARR | ||||||||
| FirstName: | NATHAN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 33 LEWIS RD | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139051048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077298156 | ||||||||
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| Practice Location | |||||||||
| Address1: | 93 PENNSYLVANIA AVE | ||||||||
| Address2: | |||||||||
| City: | BINGHAMTON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 139031645 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077622048 | ||||||||
| FaxNumber: | 6077233496 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2009 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | MA053989 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 017167 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 03779155 | 05 | NY | MEDICAID |