Basic Information
| Provider Information | |||||||||
| NPI: | 1871725556 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DELONG | ||||||||
| FirstName: | CARRIE | ||||||||
| MiddleName: | C. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | DEPT. 453 PO BOX 1000 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381480001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752625 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 1372 WESTGATE CENTER DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271032932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3366594814 | ||||||||
| FaxNumber: | 3367684745 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2009 | ||||||||
| LastUpdateDate: | 05/04/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0010-01937 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | NNI550A | 01 | NC | MEDICARE PTAN | OTHER | 1871725556 | 05 | VA | MEDICAID | 1871725556 | 05 | NC | MEDICAID | NNI550A950 | 01 | NC | MEDICARE PTAN | OTHER |