MEDICARE: MANDI CARSON PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	2048326	TX

General Provider Information

NPI Number	:	1922140359
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANDI CARSON PTA

Provider Business Mailing Address
First Line	:	1563 E 49TH ST
Second Line	:
City	:	ODESSA
State	:	TX
Zip	:	79762-4401
Country	:	US
Telephone Number	:	432-570-8782
Fax Number	:

Provider Business Practice Location Address
First Line	:	4519 N GARFIELD ST
Second Line	:	SUITE 5
City	:	MIDLAND
State	:	TX
Zip	:	79705-3415
Country	:	US
Telephone Number	:	432-570-8782
Fax Number	:	432-683-8476

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	04/21/2010

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