Healthcare Provider Details

I. General information

NPI: 1619429271
Provider Name (Legal Business Name): CASEY DEAN CARLSON ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2016
Last Update Date: 11/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 COLLEGE AVE
MANHATTAN KS
66502-3308
US

IV. Provider business mailing address

1800 COLLEGE AVE
MANHATTAN KS
66502-3308
US

V. Phone/Fax

Practice location:
  • Phone: 785-532-7244
  • Fax: 785-532-1776
Mailing address:
  • Phone: 785-532-7244
  • Fax: 785-532-1776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2401142
License Number StateKS

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2000010876
Identifier TypeOTHER
Identifier State
Identifier IssuerBOARD OF CERTIFICATION
# 2
IdentifierAT002151
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerGEORGIA BOARD OF ATHLETIC TRAINERS
# 3
Identifier2401142
Identifier TypeOTHER
Identifier StateKS
Identifier IssuerKANSAS BOARD OF HEALING ARTS ATHLETIC
# 4
IdentifierAT.0001391
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerDEPARTMENT OF REGULATORY AGENCIES ATHLETIC TRAINING

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: