Provider Demographics
NPI:1023217338
Name:CARLSON, DYNA PARAOAN (PA)
Entity Type:Individual
Prefix:
First Name:DYNA
Middle Name:PARAOAN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1426 E MOREHEAD ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2926
Practice Address - Country:US
Practice Address - Phone:704-446-6090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-16
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104112363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1023217338Medicaid
NC8102227Medicaid
NC2760094IMedicare PIN
NC2760094MMedicare PIN
NC2760094NMedicare PIN
NC2760094AMedicare PIN
NC1023217338Medicaid
NC2760094JMedicare PIN
NC2760094KMedicare PIN
NC2760094LMedicare PIN
NC2760094Medicare PIN
NC2760094DMedicare PIN
NC2760094GMedicare PIN
NCNCI5540386Medicare PIN
NC8102227Medicaid
NC2760094CMedicare PIN
NC2760094HMedicare PIN