Provider Demographics
NPI:1912982901
Name:CARPENTER, LARRY RENN (PA-C)
Entity type:Individual
Prefix:
First Name:LARRY
Middle Name:RENN
Last Name:CARPENTER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 3RD ST STE 1
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:WA
Mailing Address - Zip Code:99122-5008
Mailing Address - Country:US
Mailing Address - Phone:509-725-7501
Mailing Address - Fax:509-725-7501
Practice Address - Street 1:100 3RD ST STE 1
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:WA
Practice Address - Zip Code:99122-5008
Practice Address - Country:US
Practice Address - Phone:509-725-7501
Practice Address - Fax:509-725-7501
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60136165363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2005809Medicaid
WA295800OtherWASHINGTON STATE DEPT OF LABOR & INDUSTRIES