Provider Demographics
NPI:1740698356
Name:CARLSON, KRYSTA NICOLE (PA-C)
Entity type:Individual
Prefix:MS
First Name:KRYSTA
Middle Name:NICOLE
Last Name:CARLSON
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Gender:F
Credentials:PA-C
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Mailing Address - Street 1:1040 FLYNN RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5092
Mailing Address - Country:US
Mailing Address - Phone:805-673-3930
Mailing Address - Fax:805-659-3217
Practice Address - Street 1:1000 NEWBURY RD
Practice Address - Street 2:
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-6435
Practice Address - Country:US
Practice Address - Phone:805-498-3640
Practice Address - Fax:805-498-3641
Is Sole Proprietor?:No
Enumeration Date:2014-07-27
Last Update Date:2018-03-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAPA51782363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant