Healthcare Provider Details

I. General information

NPI: 1164469896
Provider Name (Legal Business Name): CARRIE A CLEMENS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 SENTARA CIR
WILLIAMSBURG VA
23188-5713
US

IV. Provider business mailing address

111 BULIFANTS BLVD STE B T-SYSTEM WILLIAMSBURG
WILLIAMSBURG VA
23188-5711
US

V. Phone/Fax

Practice location:
  • Phone: 757-984-6000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0110002304
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002304
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: