Provider Demographics
NPI:1134281637
Name:CARNEY, AVERY JOHN (PA-C, OT/L)
Entity type:Individual
Prefix:
First Name:AVERY
Middle Name:JOHN
Last Name:CARNEY
Suffix:
Gender:M
Credentials:PA-C, OT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:559 VINCENT ST.
Mailing Address - Street 2:SPACE BASE DELTA 1
Mailing Address - City:PETERSON SPACE FORCE BASE
Mailing Address - State:CO
Mailing Address - Zip Code:80914
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:559 VINCENT ST.
Practice Address - Street 2:SPACE BASE DELTA 1
Practice Address - City:PETERSON SPACE FORCE BASE
Practice Address - State:CO
Practice Address - Zip Code:80914
Practice Address - Country:US
Practice Address - Phone:719-723-6030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-14
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5071225X00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist