Basic Information
| Provider Information | |||||||||
| NPI: | 1932130374 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARNEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O BOX 798 | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE CENTRE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11570 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5167051373 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5304 ROAD 68 | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993018078 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095439300 | ||||||||
| FaxNumber: | 5095423059 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 12/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AS0400X | 007601 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363AS0400X | PA61005432 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 2165948 | 05 | WA | MEDICAID |