Provider Demographics
NPI:1225107667
Name:CARLSON, SHERIDA (PAC)
Entity Type:Individual
Prefix:MRS
First Name:SHERIDA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:MISS
Other - First Name:SHERIDA
Other - Middle Name:
Other - Last Name:WARREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1508
Mailing Address - Street 2:
Mailing Address - City:CLAYPOOL
Mailing Address - State:AZ
Mailing Address - Zip Code:85532-1508
Mailing Address - Country:US
Mailing Address - Phone:928-402-0952
Mailing Address - Fax:928-425-7566
Practice Address - Street 1:108 S BROAD ST
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-2602
Practice Address - Country:US
Practice Address - Phone:928-425-6592
Practice Address - Fax:928-425-7655
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2014-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1994363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ396558Medicaid
AZZ71760OtherMEDCOM MEDICAL, LLC
AZ1205962792OtherMEDCOM MEDICAL, LLC NPI
AZZ113545Medicare PIN
AZ1205962792OtherMEDCOM MEDICAL, LLC NPI