Healthcare Provider Details

I. General information

NPI: 1417990904
Provider Name (Legal Business Name): GEOFFREY CARLSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 07/09/2024
Certification Date: 07/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 S BROAD ST
CLINTON SC
29325-2505
US

IV. Provider business mailing address

300 E MCBEE AVE FL 4
GREENVILLE SC
29601-2842
US

V. Phone/Fax

Practice location:
  • Phone: 864-833-0973
  • Fax: 864-241-9290
Mailing address:
  • Phone: 864-695-6697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberOA000359L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5248
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: