Provider Demographics
NPI:1235356064
Name:CARPENTER, JEREMY DAVID (CRNA)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 51ST ST
Mailing Address - Street 2:
Mailing Address - City:VIENNA
Mailing Address - State:WV
Mailing Address - Zip Code:26105-3142
Mailing Address - Country:US
Mailing Address - Phone:304-834-1193
Mailing Address - Fax:
Practice Address - Street 1:601 AVERY ST STE 501
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5192
Practice Address - Country:US
Practice Address - Phone:304-422-3904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP009322363LA2100X
OHCOA.12311-NA367500000X
WV57744367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810019342Medicaid
OH3136529Medicaid
OH3136529Medicaid
OHH300620Medicare PIN