=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023217338
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DYNA PARAOAN CARLSON PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/16/2007
-----------------------------------------------------
Last Update Date | 10/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1748 SAINT MATTHEWS RD
-----------------------------------------------------
City | ORANGEBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29118-2441
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-536-0613
-----------------------------------------------------
Fax | 803-536-2876
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 749306
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-9306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-536-0613
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 104112
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 5103
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------