Basic Information
| Provider Information | |||||||||
| NPI: | 1518297928 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | ATC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 PERIMETER DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405174121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592681201 | ||||||||
| FaxNumber: | 8592681202 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 PERIMETER DR STE 100 | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405174121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592681201 | ||||||||
| FaxNumber: | 8592681202 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2010 | ||||||||
| LastUpdateDate: | 01/07/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT711 | KY | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.