Provider Demographics
NPI:1649220021
Name:CARLSON, ERIC S (PA-C)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:S
Last Name:CARLSON
Suffix:
Gender:M
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 1:3651 COLLEGE BLVD
Mailing Address - Street 2:
Mailing Address - City:LEAWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1910
Mailing Address - Country:US
Mailing Address - Phone:913-319-7600
Mailing Address - Fax:913-253-1702
Practice Address - Street 1:3651 COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66211-1910
Practice Address - Country:US
Practice Address - Phone:913-319-7600
Practice Address - Fax:913-253-1702
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004029282363AS0400X, 363AS0400X
KS15-00959363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS248B00002Medicare PIN
MO248A00019Medicare PIN
Q31482Medicare UPIN
KS248D486Medicare PIN