Provider Demographics
NPI:1548218191
Name:DOHERTY, CARRIE A (PA)
Entity Type:Individual
Prefix:MRS
First Name:CARRIE
Middle Name:A
Last Name:DOHERTY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:CARRIE
Other - Middle Name:A
Other - Last Name:LUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:24 BATTLE ST
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:CT
Mailing Address - Zip Code:06071-1629
Mailing Address - Country:US
Mailing Address - Phone:860-749-8887
Mailing Address - Fax:860-749-7421
Practice Address - Street 1:24 BATTLE ST
Practice Address - Street 2:
Practice Address - City:SOMERS
Practice Address - State:CT
Practice Address - Zip Code:06071-1629
Practice Address - Country:US
Practice Address - Phone:860-749-8887
Practice Address - Fax:860-749-7421
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001263363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP70756Medicare UPIN
CT970001949Medicare ID - Type Unspecified