Basic Information
| Provider Information | |||||||||
| NPI: | 1154605822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARPENTER | ||||||||
| FirstName: | AMBER | ||||||||
| MiddleName: | FANNIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FANNIN | ||||||||
| OtherFirstName: | AMBER | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2351 G RD | ||||||||
| Address2: | |||||||||
| City: | GRAND JUNCTION | ||||||||
| State: | CO | ||||||||
| PostalCode: | 815059641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9702576209 | ||||||||
| FaxNumber: | 9702576251 | ||||||||
| Practice Location | |||||||||
| Address1: | 265 BROOKVIEW CENTRE WAY | ||||||||
| Address2: | SUITE 400 | ||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379194049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8003422898 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2011 | ||||||||
| LastUpdateDate: | 12/27/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA1659 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.