Provider Demographics
NPI:1821187162
Name:CARLSON, GEORGINA (PAC)
Entity type:Individual
Prefix:MRS
First Name:GEORGINA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 KENT RD
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-3485
Mailing Address - Country:US
Mailing Address - Phone:860-355-8000
Mailing Address - Fax:860-350-6291
Practice Address - Street 1:131 KENT RD
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-3485
Practice Address - Country:US
Practice Address - Phone:860-355-8000
Practice Address - Fax:860-350-6291
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2015-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000805363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP07789Medicare UPIN
CT970001029Medicare ID - Type Unspecified