Healthcare Provider Details

I. General information

NPI: 1013115237
Provider Name (Legal Business Name): CARRIE A IRVIN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2007
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 EUBANK BLVD NE STE 6
ALBUQUERQUE NM
87112-4160
US

IV. Provider business mailing address

1524 EUBANK BLVD NE SUITE 6
ALBUQUERQUE NM
87114-4908
US

V. Phone/Fax

Practice location:
  • Phone: 505-503-8806
  • Fax: 888-503-8511
Mailing address:
  • Phone: 505-503-8806
  • Fax: 888-503-8511

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberPA2004-0015
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: