Provider Demographics
NPI:1255740098
Name:CARPENTER, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7620 DEER RUN
Mailing Address - Street 2:
Mailing Address - City:VOLENTE
Mailing Address - State:TX
Mailing Address - Zip Code:78641-6108
Mailing Address - Country:US
Mailing Address - Phone:512-351-1035
Mailing Address - Fax:
Practice Address - Street 1:1108 LAVACA ST STE 110-320
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78701-2172
Practice Address - Country:US
Practice Address - Phone:512-477-4088
Practice Address - Fax:512-482-0390
Is Sole Proprietor?:No
Enumeration Date:2014-08-06
Last Update Date:2016-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP125878364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX343379602Medicaid