Provider Demographics
NPI:1912943424
Name:NAN, CARMEN IRENA (MD)
Entity Type:Individual
Prefix:DR
First Name:CARMEN
Middle Name:IRENA
Last Name:NAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4211 VAN DYKE RD STE 200
Mailing Address - Street 2:
Mailing Address - City:LUTZ
Mailing Address - State:FL
Mailing Address - Zip Code:33558-8005
Mailing Address - Country:US
Mailing Address - Phone:813-321-6237
Mailing Address - Fax:813-463-1801
Practice Address - Street 1:4211 VAN DYKE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-8005
Practice Address - Country:US
Practice Address - Phone:813-321-6237
Practice Address - Fax:813-463-1801
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME78693207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLH07009Medicare UPIN
FL49178VMedicare PIN
FL49178YMedicare PIN
FL49178UMedicare PIN
FL49178ZMedicare PIN