Provider Demographics
NPI:1093900714
Name:CARR, VIVIAN JEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:JEAN
Last Name:CARR
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 69
Mailing Address - Street 2:
Mailing Address - City:CAMDEN ON GAULEY
Mailing Address - State:WV
Mailing Address - Zip Code:26208-0069
Mailing Address - Country:US
Mailing Address - Phone:304-226-5725
Mailing Address - Fax:304-226-3274
Practice Address - Street 1:10003 WEBSTER RD
Practice Address - Street 2:
Practice Address - City:CAMDEN ON GAULEY
Practice Address - State:WV
Practice Address - Zip Code:26208-0069
Practice Address - Country:US
Practice Address - Phone:304-226-5725
Practice Address - Fax:304-226-3274
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01039363A00000X
WV406363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0035222000Medicaid
WV01039OtherWV BOARD OF MEDICINE
WV406OtherWV BOARD OF OSTEOPATHY
WV511827Medicare Oscar/Certification
WV511897Medicare Oscar/Certification
WV5118271Medicare PIN
WV01039OtherWV BOARD OF MEDICINE
WV2030031Medicare PIN
WV2030032Medicare PIN
WVD518361Medicare PIN