Provider Demographics
NPI:1740798701
Name:CARSON, JONATHON BENNETT
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:BENNETT
Last Name:CARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 CANTERBURY BROOK LN
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-5346
Mailing Address - Country:US
Mailing Address - Phone:772-215-1195
Mailing Address - Fax:
Practice Address - Street 1:1200 CANTERBURY BROOK LN
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-5346
Practice Address - Country:US
Practice Address - Phone:772-215-1195
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22803208100000X
NC6444208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation