Provider Demographics
NPI:1114970209
Name:CARLSEN, JOHN (PA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CARLSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9125 CROSS PARK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4563
Mailing Address - Country:US
Mailing Address - Phone:865-632-5900
Mailing Address - Fax:865-374-2129
Practice Address - Street 1:9125 CROSS PARK DR STE 200
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4563
Practice Address - Country:US
Practice Address - Phone:865-632-5900
Practice Address - Fax:865-374-2129
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3495363AS0400X, 363AM0700X
CT001584363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ047734Medicaid
CT970001855Medicare ID - Type Unspecified