Provider Demographics
NPI:1316346752
Name:CARLSON, ELIZABETH M (PA-C)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:M
Other - Last Name:BARNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:370 N 120TH AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-2196
Mailing Address - Country:US
Mailing Address - Phone:616-396-5855
Mailing Address - Fax:616-396-5720
Practice Address - Street 1:370 N 120TH AVE
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49424-2196
Practice Address - Country:US
Practice Address - Phone:616-396-5855
Practice Address - Fax:616-396-5720
Is Sole Proprietor?:No
Enumeration Date:2014-08-21
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3404363A00000X
363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1316346752Medicaid
MIEB007542OtherBCBS