Basic Information
| Provider Information | |||||||||
| NPI: | 1538331921 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | CASEY | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EVANS | ||||||||
| OtherFirstName: | CASEY | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1593 E POLSTON AVE | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 83854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082622300 | ||||||||
| FaxNumber: | 2082622390 | ||||||||
| Practice Location | |||||||||
| Address1: | 1551 E MULLAN AVE BLDG A STE 200D | ||||||||
| Address2: | |||||||||
| City: | POST FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 838544868 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2086186070 | ||||||||
| FaxNumber: | 2086188903 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2008 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA150161 | OR | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA60371391 | WA | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA-2000 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | PA-2000 | ID | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | PA-2000 | ID | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1538331921 | 05 | ID | MEDICAID |