Provider Demographics
NPI:1790936953
Name:ELLERBE CARLSON, MISTY L (PA)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:L
Last Name:ELLERBE CARLSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 ROSS STREET
Mailing Address - Street 2:
Mailing Address - City:OAK GROVE
Mailing Address - State:LA
Mailing Address - Zip Code:71263
Mailing Address - Country:US
Mailing Address - Phone:318-428-3237
Mailing Address - Fax:318-428-6180
Practice Address - Street 1:706 ROSS STREET
Practice Address - Street 2:
Practice Address - City:OAK GROVE
Practice Address - State:LA
Practice Address - Zip Code:71263
Practice Address - Country:US
Practice Address - Phone:318-428-3237
Practice Address - Fax:318-428-6180
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-07
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200207363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical