Provider Demographics
NPI:1417990904
Name:CARLSON, GEOFFREY (PA)
Entity type:Individual
Prefix:
First Name:GEOFFREY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-695-6697
Mailing Address - Fax:
Practice Address - Street 1:210 S BROAD ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:SC
Practice Address - Zip Code:29325-2505
Practice Address - Country:US
Practice Address - Phone:864-833-0973
Practice Address - Fax:864-241-9290
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2024-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA000359L363AM0700X
SC5248363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAS48168Medicare UPIN