Provider Demographics
NPI:1174006928
Name:CARPENTER, ROBERT WALTER (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WALTER
Last Name:CARPENTER
Suffix:
Gender:M
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 1:1208 HILLTOP DR STE 203
Mailing Address - Street 2:
Mailing Address - City:ROCK SPRINGS
Mailing Address - State:WY
Mailing Address - Zip Code:82901-5859
Mailing Address - Country:US
Mailing Address - Phone:307-382-9420
Mailing Address - Fax:
Practice Address - Street 1:1208 HILLTOP DR STE 203
Practice Address - Street 2:
Practice Address - City:ROCK SPRINGS
Practice Address - State:WY
Practice Address - Zip Code:82901-5859
Practice Address - Country:US
Practice Address - Phone:307-382-9420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-07
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WYPT869363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program