Provider Demographics
NPI:1619011699
Name:CARVER, MARYCOLETTE (NP)
Entity Type:Individual
Prefix:
First Name:MARYCOLETTE
Middle Name:
Last Name:CARVER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S POLLARD ST
Mailing Address - Street 2:
Mailing Address - City:VINTON
Mailing Address - State:VA
Mailing Address - Zip Code:24179-2502
Mailing Address - Country:US
Mailing Address - Phone:540-983-6700
Mailing Address - Fax:
Practice Address - Street 1:415 S POLLARD ST
Practice Address - Street 2:
Practice Address - City:VINTON
Practice Address - State:VA
Practice Address - Zip Code:24179-2502
Practice Address - Country:US
Practice Address - Phone:540-983-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2008-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201368207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1619011699Medicaid
P16276Medicare UPIN
VA1619011699Medicaid
014658C04Medicare PIN
NC2599383Medicare ID - Type Unspecified