Provider Demographics
NPI:1629771282
Name:MADSON, CARISSA SUMMERS (DO)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:SUMMERS
Last Name:MADSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 LEWIS TURNER BLVD APT M103
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-7211
Mailing Address - Country:US
Mailing Address - Phone:707-567-3830
Mailing Address - Fax:
Practice Address - Street 1:1000 E MOUNTAIN DR
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18711-0001
Practice Address - Country:US
Practice Address - Phone:707-567-3830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-23
Last Update Date:2023-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program