Provider Demographics
NPI:1013115237
Name:IRVIN, CARRIE A (PA-C)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:A
Last Name:IRVIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 EUBANK BLVD NE SUITE 6
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87114-4908
Mailing Address - Country:US
Mailing Address - Phone:505-503-8806
Mailing Address - Fax:888-503-8511
Practice Address - Street 1:1524 EUBANK BLVD NE STE 6
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-4160
Practice Address - Country:US
Practice Address - Phone:505-503-8806
Practice Address - Fax:888-503-8511
Is Sole Proprietor?:No
Enumeration Date:2007-07-10
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMPA2004-0015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM97175323Medicaid
342729504Medicare PIN