Provider Demographics
NPI:1629011663
Name:CARLSON, MARY ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
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:PO BOX 467
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:KS
Mailing Address - Zip Code:67114-0467
Mailing Address - Country:US
Mailing Address - Phone:316-284-6400
Mailing Address - Fax:316-284-6490
Practice Address - Street 1:1102 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:MCPHERSON
Practice Address - State:KS
Practice Address - Zip Code:67460-2318
Practice Address - Country:US
Practice Address - Phone:620-245-5000
Practice Address - Fax:620-245-5099
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS15-00250363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS023081OtherBLUE CROSS BLUE SHIELD
KS023081Medicare PIN