Provider Demographics
NPI:1063645992
Name:CARLSON, ELIZABETH MOYLE (PA-C)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MOYLE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:WOOD
Other - Last Name:MOYLE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 1727
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81502-1727
Mailing Address - Country:US
Mailing Address - Phone:970-623-8860
Mailing Address - Fax:970-623-8869
Practice Address - Street 1:735 WHITE AVE
Practice Address - Street 2:
Practice Address - City:GRAND JCT
Practice Address - State:CO
Practice Address - Zip Code:81501-3441
Practice Address - Country:US
Practice Address - Phone:970-248-5880
Practice Address - Fax:970-241-1112
Is Sole Proprietor?:No
Enumeration Date:2009-08-26
Last Update Date:2024-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2780363AS0400X
COPA.0002780363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO62824279Medicaid