Provider Demographics
NPI:1396860565
Name:CARLSON, RAYMOND JOHN JR (PA)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:JOHN
Last Name:CARLSON
Suffix:JR
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:NMOTC
Mailing Address - Street 2:220 HOVEY ROAD
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32508
Mailing Address - Country:US
Mailing Address - Phone:619-532-5098
Mailing Address - Fax:
Practice Address - Street 1:NMOTC
Practice Address - Street 2:220 HOVEY ROAD
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32508
Practice Address - Country:US
Practice Address - Phone:619-532-5098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17947363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADQ697ZMedicare PIN
VAD0000Medicare UPIN