Basic Information
| Provider Information | |||||||||
| NPI: | 1851611016 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARTER | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | MARK | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8422 E SHEA BLVD | ||||||||
| Address2: | 103 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852606661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804786620 | ||||||||
| FaxNumber: | 4804786628 | ||||||||
| Practice Location | |||||||||
| Address1: | 8422 E SHEA BLVD | ||||||||
| Address2: | 103 | ||||||||
| City: | SCOTTSDALE | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852606661 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4804786620 | ||||||||
| FaxNumber: | 4804786628 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2010 | ||||||||
| LastUpdateDate: | 06/28/2010 | ||||||||
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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 | 163W00000X | RN 02769 | AZ | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN 590080 | PA | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN 650968 | CA | N | Nursing Service Providers | Registered Nurse | 163W00000X | RN 357922 | CA | N | Nursing Service Providers | Registered Nurse | 367500000X | CRNA 084670 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 528901 | 05 | AZ | MEDICAID |