Provider Demographics
NPI:1821630146
Name:CARLSON, RACHEL NICOLE (PA-C, ATC)
Entity Type:Individual
Prefix:
First Name:RACHEL
Middle Name:NICOLE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:RACHEL
Other - Middle Name:NICOLE
Other - Last Name:BIANCA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ATC
Mailing Address - Street 1:560 S LAKEWOOD DR STE 101
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:FL
Mailing Address - Zip Code:33511-5015
Mailing Address - Country:US
Mailing Address - Phone:813-978-9700
Mailing Address - Fax:813-558-6186
Practice Address - Street 1:560 S LAKEWOOD DR STE 101
Practice Address - Street 2:
Practice Address - City:BRANDON
Practice Address - State:FL
Practice Address - Zip Code:33511-5015
Practice Address - Country:US
Practice Address - Phone:813-978-9700
Practice Address - Fax:813-558-6186
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9112491363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLMA473OtherMEDICARE PIN
FL105589900Medicaid