Provider Demographics
NPI:1851771794
Name:CARPENTER, REGINA LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:REGINA
Middle Name:LEE
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:REGINA
Other - Middle Name:LEE
Other - Last Name:BRADY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11050 MOUNT BELVEDERE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT DRUM
Mailing Address - State:NY
Mailing Address - Zip Code:13602-5438
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11050 MOUNT BELVEDERE BLVD
Practice Address - Street 2:
Practice Address - City:FT DRUM
Practice Address - State:NY
Practice Address - Zip Code:13602
Practice Address - Country:US
Practice Address - Phone:315-774-5566
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-05
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA80593207Q00000X
VA0116027930207Q00000X
ALMD.37410207Q00000X
VA0101262798207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
1851771794OtherNPI