Provider Demographics
NPI:1033390398
Name:HOLTZCLAW, CARSON SHETLEY (PA-C)
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:SHETLEY
Last Name:HOLTZCLAW
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6841 FERN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-4175
Mailing Address - Country:US
Mailing Address - Phone:318-868-2273
Mailing Address - Fax:318-868-4219
Practice Address - Street 1:6841 FERN AVE STE 100
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-4175
Practice Address - Country:US
Practice Address - Phone:318-868-2273
Practice Address - Fax:318-868-4219
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07206363AM0700X
LAPA200181363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1157872Medicaid
LA1157872Medicaid