Provider Demographics
NPI:1003624958
Name:CARPENTER, TIA (CSFA)
Entity type:Individual
Prefix:
First Name:TIA
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4415 GANNON RD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23703-4830
Mailing Address - Country:US
Mailing Address - Phone:814-590-3812
Mailing Address - Fax:
Practice Address - Street 1:4415 GANNON RD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23703-4830
Practice Address - Country:US
Practice Address - Phone:814-590-3812
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-24
Last Update Date:2024-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0136000424246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant