Provider Demographics
NPI:1326029257
Name:HUMPHRY, CAROL (MD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:
Last Name:HUMPHRY
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 1:808 SE CHKALOV DR
Mailing Address - Street 2:STE. 3 - 165
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:528 CHIEF EDDIE HOFFMAN HWY
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559
Practice Address - Country:US
Practice Address - Phone:907-543-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-08
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75480207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E91949Medicare UPIN