Provider Demographics
NPI:1457323735
Name:CARLSON, TINA Y (PA-C)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:Y
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6420 PROSPECT AVE
Mailing Address - Street 2:SUITE T411
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64132-4147
Mailing Address - Country:US
Mailing Address - Phone:816-363-2500
Mailing Address - Fax:816-363-8741
Practice Address - Street 1:6420 PROSPECT AVE
Practice Address - Street 2:SUITE T411
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64132-4147
Practice Address - Country:US
Practice Address - Phone:816-363-2500
Practice Address - Fax:816-363-8741
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00920363AS0400X
MO2004006980363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO279C798Medicare ID - Type Unspecified