Healthcare Provider Details

I. General information

NPI: 1275500399
Provider Name (Legal Business Name): GLORIA JEAN PADILLA-CARLSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S LINCOLN ST
AUGUSTA MI
49012-9758
US

IV. Provider business mailing address

600 S LINCOLN ST
AUGUSTA MI
49012-9758
US

V. Phone/Fax

Practice location:
  • Phone: 269-731-5762
  • Fax: 269-731-5764
Mailing address:
  • Phone: 269-731-5762
  • Fax: 269-731-5764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601005122
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: