Healthcare Provider Details

I. General information

NPI: 1336575778
Provider Name (Legal Business Name): SARAH CARSON BRANTLEY P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH ELIZABETH CARSON

II. Dates (important events)

Enumeration Date: 09/17/2013
Last Update Date: 10/13/2021
Certification Date: 10/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 E BERT KOUNS INDUSTRIAL LOOP STE 210
SHREVEPORT LA
71105-6000
US

IV. Provider business mailing address

1455 E BERT KOUNS INDUSTRIAL LOOP
SHREVEPORT LA
71105-6000
US

V. Phone/Fax

Practice location:
  • Phone: 318-798-4623
  • Fax:
Mailing address:
  • Phone: 318-798-4623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.200659
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA.200659
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: