Healthcare Provider Details

I. General information

NPI: 1134281637
Provider Name (Legal Business Name): AVERY JOHN CARNEY PA-C, OT/L
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 VINCENT ST. SPACE BASE DELTA 1
PETERSON SPACE FORCE BASE CO
80914
US

IV. Provider business mailing address

559 VINCENT ST. SPACE BASE DELTA 1
PETERSON SPACE FORCE BASE CO
80914
US

V. Phone/Fax

Practice location:
  • Phone: 719-723-6030
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5071
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: