Provider Demographics
NPI:1487026977
Name:CARPENTER, KEVIN RYAN
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:RYAN
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5024 V ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1511
Mailing Address - Country:US
Mailing Address - Phone:925-525-4545
Mailing Address - Fax:
Practice Address - Street 1:4610 X ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2200
Practice Address - Country:US
Practice Address - Phone:925-525-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA160146207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine