Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207YX0905X | Otolaryngology/Facial Plastic Surgery | 28759 | IA |
NPI | 1629028956 |
---|---|
Provider Name | Kevin Michael Carpenter |
First Address | Cedar Rapids, IA 52406-3178 |
Second Address | Cedar Rapids, IA 52403-2404 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2006 |
Last Update Date | 11/09/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0219329 | (05) | IA |
22504 | BLUE CROSS/BLUE SHIELD (01) | IA |
G31586 | (02) | IA |