Provider Demographics
NPI:1679956569
Name:CARLSON, MARCELLA LEE (PA)
Entity Type:Individual
Prefix:MRS
First Name:MARCELLA
Middle Name:LEE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:MARCELLA
Other - Middle Name:LEE
Other - Last Name:ETHINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1425 PORTLAND AVE
Mailing Address - Street 2:ROCHESTER REGIONAL HEALTH
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621
Mailing Address - Country:US
Mailing Address - Phone:585-338-1200
Mailing Address - Fax:
Practice Address - Street 1:1425 PORTLAND AVE
Practice Address - Street 2:ROCHESTER REGIONAL HEALTH
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621
Practice Address - Country:US
Practice Address - Phone:585-338-1200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY018715363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04295236Medicaid