Provider Demographics
NPI:1467801357
Name:RISNER, CARLA (CSFA)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:RISNER
Suffix:
Gender:F
Credentials:CSFA
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:LEE
Other - Last Name:RISNER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CSFA
Mailing Address - Street 1:357 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:CAMDEN
Mailing Address - State:OH
Mailing Address - Zip Code:45311-9601
Mailing Address - Country:US
Mailing Address - Phone:937-533-7727
Mailing Address - Fax:
Practice Address - Street 1:357 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:CAMDEN
Practice Address - State:OH
Practice Address - Zip Code:45311-9601
Practice Address - Country:US
Practice Address - Phone:937-533-7727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-10
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZC0007X
OH152974207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine