Basic Information
| Provider Information | |||||||||
| NPI: | 1366069270 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARPENTER | ||||||||
| FirstName: | GNATHAN | ||||||||
| MiddleName: | ANDREW | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | MSN, APRN, PMHNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2650 RIDGE AVE. | ||||||||
| Address2: | DEPT. OF PSYCHIATRY | ||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602022113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475702540 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2650 RIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | EVANSTON | ||||||||
| State: | IL | ||||||||
| PostalCode: | 602011700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475702000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2020 | ||||||||
| LastUpdateDate: | 07/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 209021456 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | 209021456 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.