Provider Demographics
NPI:1639970080
Name:CARLSON, MIA LEIGH (MMSPA)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:LEIGH
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MMSPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 GRAND AVE STE 201
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-6300
Mailing Address - Country:US
Mailing Address - Phone:201-608-5656
Mailing Address - Fax:201-608-5650
Practice Address - Street 1:300 GRAND AVE STE 201
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-6300
Practice Address - Country:US
Practice Address - Phone:201-608-5656
Practice Address - Fax:201-608-5650
Is Sole Proprietor?:No
Enumeration Date:2025-03-21
Last Update Date:2025-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant