Provider Demographics
NPI:1861038044
Name:CARSON, MARA DAWNE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:DAWNE
Last Name:CARSON
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26224 N TATUM BLVD STE 15A
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85050-7500
Mailing Address - Country:US
Mailing Address - Phone:480-663-9632
Mailing Address - Fax:480-419-6782
Practice Address - Street 1:26224 N TATUM BLVD STE 15A
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85050-7500
Practice Address - Country:US
Practice Address - Phone:480-663-9632
Practice Address - Fax:480-419-6782
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDRN259811363LA2100X
GARN259811363LG0600X
AZ259985363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ092948Medicaid