Provider Demographics
NPI:1942660006
Name:CARLSON, GARRETT S
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:S
Last Name:CARLSON
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 1:568B N CHAMBERLAIN RD
Mailing Address - Street 2:
Mailing Address - City:ESMOND
Mailing Address - State:IL
Mailing Address - Zip Code:60129-9308
Mailing Address - Country:US
Mailing Address - Phone:815-901-4706
Mailing Address - Fax:
Practice Address - Street 1:1 ATWELL RD
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1301
Practice Address - Country:US
Practice Address - Phone:607-547-3456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2023-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY19860363AM0700X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical