Provider Demographics
NPI:1659870343
Name:CARMACK, IRINA (NP)
Entity Type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:CARMACK
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 1:1150 MAIN ST STE 3
Mailing Address - Street 2:
Mailing Address - City:WATSONVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95076-3760
Mailing Address - Country:US
Mailing Address - Phone:815-289-0039
Mailing Address - Fax:
Practice Address - Street 1:2101 FOREST AVE STE 220A
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1473
Practice Address - Country:US
Practice Address - Phone:408-295-8628
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008283363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily