Provider Demographics
NPI: | 1184659674 |
---|---|
Name: | SUN, CARRIE L (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | CARRIE |
Middle Name: | L |
Last Name: | SUN |
Suffix: | |
Gender: | F |
Credentials: | MD |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 800 N 5TH AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | SEQUIM |
Mailing Address - State: | WA |
Mailing Address - Zip Code: | 98382-3045 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 360-565-0999 |
Mailing Address - Fax: | 360-582-4221 |
Practice Address - Street 1: | 800 N 5TH AVE |
Practice Address - Street 2: | |
Practice Address - City: | SEQUIM |
Practice Address - State: | WA |
Practice Address - Zip Code: | 98382-3045 |
Practice Address - Country: | US |
Practice Address - Phone: | 360-565-0999 |
Practice Address - Fax: | 360-582-4221 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-12 |
Last Update Date: | 2020-11-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MD | D0062604 | 207R00000X |
WA | MD00046290 | 207R00000X |
PA | MD444615 | 207R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 250470 | Other | MEDICARE GROUP |
IN | 000000544173 | Other | ANTHEM PIN |
IN | 200859330C | Other | MEDICAID GROUP |
PA | 103280724 | Medicaid | |
IN | 200529610 | Medicaid | |
I42731 | Medicare UPIN |