Provider Demographics
NPI:1629711056
Name:CARSON, JUSTIN (PTA)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:CARSON
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 MONTANA AVE
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-1265
Mailing Address - Country:US
Mailing Address - Phone:817-879-1385
Mailing Address - Fax:
Practice Address - Street 1:201 SEAGRASS DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32407-2597
Practice Address - Country:US
Practice Address - Phone:850-749-5358
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-14
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2153497225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant