Provider Demographics
NPI:1255629267
Name:CARPENTER, TODD M (NP)
Entity type:Individual
Prefix:
First Name:TODD
Middle Name:M
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1268 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-2219
Mailing Address - Country:US
Mailing Address - Phone:509-758-9524
Mailing Address - Fax:509-758-8258
Practice Address - Street 1:1268 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:WA
Practice Address - Zip Code:99403-2219
Practice Address - Country:US
Practice Address - Phone:509-758-9524
Practice Address - Fax:509-758-8258
Is Sole Proprietor?:No
Enumeration Date:2011-07-12
Last Update Date:2023-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1086A363L00000X
WAAP60241846363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP01205379OtherRR MEDICARE
WA2026739Medicaid
ID0308802OtherL & I (OUT OF NETWORK)
WA314270OtherL & I MEDICAL PROVIDER NETWORK
IDP01198538OtherRR MEDICARE
ID1255629267Medicaid
WAG8917788Medicare PIN