Healthcare Provider Details

I. General information

NPI: 1255986097
Provider Name (Legal Business Name): BRIAN RICHARD CARLSON PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2019
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 3RD ST
FORT POLK LA
71459-5102
US

IV. Provider business mailing address

1585 3RD ST BLDG 285
FORT JOHNSON LA
71459-5102
US

V. Phone/Fax

Practice location:
  • Phone: 614-371-8434
  • Fax:
Mailing address:
  • Phone: 614-371-8434
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT018930
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: