Provider Demographics
NPI:1538331921
Name:CARLSON, CASEY LYNN (PA-C)
Entity Type:Individual
Prefix:MS
First Name:CASEY
Middle Name:LYNN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:CASEY
Other - Middle Name:LYNN
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854
Mailing Address - Country:US
Mailing Address - Phone:208-262-2300
Mailing Address - Fax:208-262-2390
Practice Address - Street 1:1551 E MULLAN AVE BLDG A STE 200D
Practice Address - Street 2:
Practice Address - City:POST FALLS
Practice Address - State:ID
Practice Address - Zip Code:83854-4868
Practice Address - Country:US
Practice Address - Phone:208-618-6070
Practice Address - Fax:208-618-8903
Is Sole Proprietor?:No
Enumeration Date:2008-03-26
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA150161363A00000X
WAPA60371391363A00000X
IDPA-2000363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1538331921Medicaid