Provider Demographics
NPI:1104858323
Name:KINCAID-WASHINGTON, CARRIE (DPM)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:KINCAID-WASHINGTON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 CENTRAL PARK
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23803-4551
Mailing Address - Country:US
Mailing Address - Phone:804-322-3996
Mailing Address - Fax:
Practice Address - Street 1:119 CENTRAL PARK
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23803-4551
Practice Address - Country:US
Practice Address - Phone:804-322-3996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103000808213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA9330429Medicaid
VA9330429Medicaid
VA480000220Medicare ID - Type UnspecifiedPROVIDER NUMBER