Provider Demographics
NPI:1497713804
Name:CARTER, CONAN M (NP)
Entity Type:Individual
Prefix:
First Name:CONAN
Middle Name:M
Last Name:CARTER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:883 UNION ST
Mailing Address - Street 2:
Mailing Address - City:SHELBYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37160-2607
Mailing Address - Country:US
Mailing Address - Phone:931-685-1145
Mailing Address - Fax:931-685-8014
Practice Address - Street 1:12 MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:LYNCHBURG
Practice Address - State:TN
Practice Address - Zip Code:37352-8373
Practice Address - Country:US
Practice Address - Phone:931-759-5044
Practice Address - Fax:931-759-5042
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11936363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN36430621Medicaid
TN4160176OtherBCBS
TN3643062Medicare PIN
TNQ69095Medicare UPIN
TN36430621Medicaid