Healthcare Provider Details

I. General information

NPI: 1013623529
Provider Name (Legal Business Name): ALEX MICHAEL CARR FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2023
Last Update Date: 01/27/2023
Certification Date: 01/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 S 5TH ST
MONTPELIER ID
83254-1597
US

IV. Provider business mailing address

PO BOX 293
GEORGETOWN ID
83239-0293
US

V. Phone/Fax

Practice location:
  • Phone: 208-847-1630
  • Fax:
Mailing address:
  • Phone: 208-705-0229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number56200
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: