Provider Demographics
NPI:1649806175
Name:HAUSMANN, CARSON TYLER
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:TYLER
Last Name:HAUSMANN
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 1:1814 SEAY CT
Mailing Address - Street 2:
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-3268
Mailing Address - Country:US
Mailing Address - Phone:561-308-8620
Mailing Address - Fax:
Practice Address - Street 1:2626 CAPITAL MEDICAL BLVD
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-4499
Practice Address - Country:US
Practice Address - Phone:561-308-8620
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11007726363LF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program