Provider Demographics
NPI:1972881951
Name:CARLSON, GREGG (PA)
Entity Type:Individual
Prefix:MR
First Name:GREGG
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:848 RIVER RD
Mailing Address - Street 2:
Mailing Address - City:CHATHAM
Mailing Address - State:NJ
Mailing Address - Zip Code:07928-1047
Mailing Address - Country:US
Mailing Address - Phone:646-327-7194
Mailing Address - Fax:
Practice Address - Street 1:321 E 34TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-4942
Practice Address - Country:US
Practice Address - Phone:212-340-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-25
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009854-1363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical