Provider Demographics
NPI:1659890259
Name:POWELL, CARSON LANE (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:CARSON
Middle Name:LANE
Last Name:POWELL
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3202 SHENANDOAH DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701-7449
Mailing Address - Country:US
Mailing Address - Phone:417-540-8634
Mailing Address - Fax:
Practice Address - Street 1:3001 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-7457
Practice Address - Country:US
Practice Address - Phone:417-540-8634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2017-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT67472255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer