Basic Information
| Provider Information | |||||||||
| NPI: | 1669645180 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARVER | ||||||||
| FirstName: | LEA | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1239 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480991239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2488246600 | ||||||||
| FaxNumber: | 2483241477 | ||||||||
| Practice Location | |||||||||
| Address1: | 4800 FREDERICKSBURG RD | ||||||||
| Address2: | STE 127 | ||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782293628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107335072 | ||||||||
| FaxNumber: | 2107338649 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2008 | ||||||||
| LastUpdateDate: | 03/31/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 639892 | TX | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 639892 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 154710101 | 05 | TX | MEDICAID |