Basic Information
| Provider Information | |||||||||
| NPI: | 1821630146 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | RACHEL | ||||||||
| MiddleName: | NICOLE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C, ATC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BIANCA | ||||||||
| OtherFirstName: | RACHEL | ||||||||
| OtherMiddleName: | NICOLE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ATC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 560 S LAKEWOOD DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139789700 | ||||||||
| FaxNumber: | 8135586186 | ||||||||
| Practice Location | |||||||||
| Address1: | 560 S LAKEWOOD DR STE 101 | ||||||||
| Address2: | |||||||||
| City: | BRANDON | ||||||||
| State: | FL | ||||||||
| PostalCode: | 335115015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139789700 | ||||||||
| FaxNumber: | 8135586186 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/09/2019 | ||||||||
| LastUpdateDate: | 02/26/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9112491 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MA473 | 01 | FL | MEDICARE PIN | OTHER | 105589900 | 05 | FL | MEDICAID |