Provider Demographics
NPI:1174514558
Name:CARLSON, KACIE R (PA-C)
Entity type:Individual
Prefix:
First Name:KACIE
Middle Name:R
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 9805
Mailing Address - Street 2:300 GEORGE ST, 6TH FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06536-0805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15 YORK ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3221
Practice Address - Country:US
Practice Address - Phone:203-785-4632
Practice Address - Fax:203-785-3315
Is Sole Proprietor?:No
Enumeration Date:2005-11-03
Last Update Date:2008-12-05
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT970001968Medicare PIN