Basic Information
| Provider Information | |||||||||
| NPI: | 1841811619 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | KAYLA | ||||||||
| MiddleName: | ANNE | ||||||||
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| Credential: | PA-S | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2500 NE NEFF RD | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977016015 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413824321 | ||||||||
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| Practice Location | |||||||||
| Address1: | 480 NE A ST | ||||||||
| Address2: | |||||||||
| City: | MADRAS | ||||||||
| State: | OR | ||||||||
| PostalCode: | 977411844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5414754800 | ||||||||
| FaxNumber: | 5414754805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2020 | ||||||||
| LastUpdateDate: | 03/01/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA206996 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.