Provider Demographics
NPI:1013039288
Name:CARNAHAN CLINIC PLLC
Entity Type:Organization
Organization Name:CARNAHAN CLINIC PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:E
Authorized Official - Last Name:CARNAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:662-536-4646
Mailing Address - Street 1:7900 AIRWAYS BLVD BLDG A STE 6
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671
Mailing Address - Country:US
Mailing Address - Phone:662-536-4646
Mailing Address - Fax:662-536-4443
Practice Address - Street 1:7900 AIRWAYS BLVD BLDG A STE 6
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4113
Practice Address - Country:US
Practice Address - Phone:662-536-4646
Practice Address - Fax:662-536-4443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS16014207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1184602450OtherTAMMY FNP NPI
1174501449OtherDR. CARNAHAN NPI
MSC03390Medicare ID - Type Unspecified
MS080004158Medicare PIN
1184602450OtherTAMMY FNP NPI