Provider Demographics
NPI:1144220526
Name:CARLSON, CHRISTOPHER R (PA-C, ATC)
Entity Type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:R
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PA-C, ATC
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 31917
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85275-1917
Mailing Address - Country:US
Mailing Address - Phone:480-350-3800
Mailing Address - Fax:
Practice Address - Street 1:4824 E BASELINE RD
Practice Address - Street 2:SUITE 113
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-4676
Practice Address - Country:US
Practice Address - Phone:480-350-3800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1593363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ153982Medicaid
AZ153982Medicaid
AZR97567Medicare UPIN