Provider Demographics
NPI:1023086089
Name:CARSON, NICOLE A (PA)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:A
Last Name:CARSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4897 YORK ROAD
Mailing Address - Street 2:PO BOX 278
Mailing Address - City:BUCKINGHAM
Mailing Address - State:PA
Mailing Address - Zip Code:18912
Mailing Address - Country:US
Mailing Address - Phone:215-794-7471
Mailing Address - Fax:215-794-2576
Practice Address - Street 1:4897 YORK ROAD
Practice Address - Street 2:
Practice Address - City:BUCKINGHAM
Practice Address - State:PA
Practice Address - Zip Code:18912
Practice Address - Country:US
Practice Address - Phone:215-794-7471
Practice Address - Fax:215-794-2576
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA051781363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAQ26022Medicare UPIN
PA084355JZWMedicare ID - Type Unspecified