Provider Demographics
NPI:1558582940
Name:CARSON, COLE JAYMES (PT)
Entity Type:Individual
Prefix:MR
First Name:COLE
Middle Name:JAYMES
Last Name:CARSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3677 COLLEGE RD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3712
Mailing Address - Country:US
Mailing Address - Phone:907-479-3800
Mailing Address - Fax:907-479-9195
Practice Address - Street 1:3677 COLLEGE RD
Practice Address - Street 2:SUITE 12
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99709-3712
Practice Address - Country:US
Practice Address - Phone:907-479-3800
Practice Address - Fax:907-479-9195
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK306225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1972643138OtherNPI # EQUINOX, INC
AKPT0306Medicaid
AK00WCPGCAMedicare ID - Type Unspecified