Provider Demographics
NPI:1437814480
Name:CARLSON, KIRSTEN BLYTHE (PA-C)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:BLYTHE
Last Name:CARLSON
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 1:602 ASCOT DR
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29501-1913
Mailing Address - Country:US
Mailing Address - Phone:240-539-4292
Mailing Address - Fax:
Practice Address - Street 1:1304 W BOBO NEWSOM HWY
Practice Address - Street 2:
Practice Address - City:HARTSVILLE
Practice Address - State:SC
Practice Address - Zip Code:29550-4710
Practice Address - Country:US
Practice Address - Phone:843-339-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-04
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4288363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant