Basic Information
Provider Information | |||||||||
NPI: | 1629250162 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARNES | ||||||||
FirstName: | PATRICK | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | AA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3355 GLENDALE AVE 3RD FL | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436142426 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193835322 | ||||||||
FaxNumber: | 4193836235 | ||||||||
Practice Location | |||||||||
Address1: | 3000 ARLINGTON AVE | ||||||||
Address2: |   | ||||||||
City: | TOLEDO | ||||||||
State: | OH | ||||||||
PostalCode: | 436142595 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4193833556 | ||||||||
FaxNumber: | 4193833550 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/27/2007 | ||||||||
LastUpdateDate: | 08/24/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367H00000X | 67000129 | OH | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Anesthesiologist Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 67000129 | 01 | OH | LICENSE | OTHER | 784 | 01 |   | CERTIFICATION | OTHER | 2832822 | 05 | OH |   | MEDICAID |