1184902165 NPI number — DONNELL KAJAUN CARSON PA-C

Table of content: DONNELL KAJAUN CARSON PA-C (NPI 1184902165)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1184902165 NPI number — DONNELL KAJAUN CARSON PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARSON
Provider First Name:
DONNELL
Provider Middle Name:
KAJAUN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1184902165
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1010 BRIAR NET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CONROE
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77301-1890
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-294-2192
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1010 BRIAR NET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CONROE
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77301-1890
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-294-2192
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  PA07043 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363AS0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 741889584 . This is a "TAX ID #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: B0178864 . This is a "DPS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: PA07043 . This is a "TEXAS LICENSE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com