MEDICARE: AMANDA CARSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	AP144187	TX

General Provider Information

NPI Number	:	1124668744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA CARSON

Provider Business Mailing Address
First Line	:	PO BOX 130593
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77393-0593
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3131 EASTSIDE ST STE 200
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77098-1919
Country	:	US
Telephone Number	:	866-647-5534
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/11/2020
Last Update Date	:	01/11/2020

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