Provider Demographics
NPI:1942516224
Name:CARLSON, COURTNEY R (PA-C)
Entity Type:Individual
Prefix:MS
First Name:COURTNEY
Middle Name:R
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:676 N. ST. CLAIR
Mailing Address - Street 2:SUITE 1835
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-3129
Mailing Address - Country:US
Mailing Address - Phone:312-926-3535
Mailing Address - Fax:312-926-3585
Practice Address - Street 1:676 N. ST. CLAIR
Practice Address - Street 2:SUITE 1835
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-3129
Practice Address - Country:US
Practice Address - Phone:312-926-3535
Practice Address - Fax:312-926-3585
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2014-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.003873363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
212210035Medicare PIN