Provider Demographics
NPI:1033118849
Name:CARPENTER, KITRIN LANCE (PAC)
Entity Type:Individual
Prefix:
First Name:KITRIN
Middle Name:LANCE
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:967 HANCOCK RD STE 133
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-5142
Mailing Address - Country:US
Mailing Address - Phone:928-224-0064
Mailing Address - Fax:480-842-8608
Practice Address - Street 1:967 HANCOCK RD STE 133
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-5142
Practice Address - Country:US
Practice Address - Phone:928-224-0064
Practice Address - Fax:480-842-8608
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1830363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ356297Medicaid
S18556Medicare UPIN
AZ109391Medicare PIN