Provider Demographics
NPI:1508404005
Name:CARLSON, CHRISTINA KVISTAD (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:KVISTAD
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 1:108 NEW LONDON TPKE STE 1
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2645
Mailing Address - Country:US
Mailing Address - Phone:860-889-3052
Mailing Address - Fax:
Practice Address - Street 1:108 NEW LONDON TPKE STE 1
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2645
Practice Address - Country:US
Practice Address - Phone:860-889-3052
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-16
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4849363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
1508404005OtherNPI