Provider Demographics
NPI:1417258583
Name:CARLSSON, INGRID MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:MARIE
Last Name:CARLSSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 WADE AVE
Mailing Address - Street 2:SPRING GROVE HOSPITAL CENTER
Mailing Address - City:CATONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21228
Mailing Address - Country:US
Mailing Address - Phone:140-402-6000
Mailing Address - Fax:
Practice Address - Street 1:55 WADE AVE
Practice Address - Street 2:
Practice Address - City:CATONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21228-4663
Practice Address - Country:US
Practice Address - Phone:410-402-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-05
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004473363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant