Provider Demographics
NPI:1508889312
Name:CARBO, MARK A (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:A
Last Name:CARBO
Suffix:
Gender:M
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 1:3444 MASONIC DRIVE
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301
Mailing Address - Country:US
Mailing Address - Phone:318-473-9556
Mailing Address - Fax:318-441-8310
Practice Address - Street 1:3444 MASONIC DRIVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301
Practice Address - Country:US
Practice Address - Phone:318-473-9556
Practice Address - Fax:318-441-8310
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10575363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAQ16886Medicare UPIN
5C616P465Medicare ID - Type Unspecified