Provider Demographics
NPI:1730186198
Name:VANSELOW, CARL ROBERT (PA)
Entity type:Individual
Prefix:
First Name:CARL
Middle Name:ROBERT
Last Name:VANSELOW
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3805 E BELL RD STE 3100
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2136
Mailing Address - Country:US
Mailing Address - Phone:602-494-3656
Mailing Address - Fax:602-867-3862
Practice Address - Street 1:3805 E BELL RD
Practice Address - Street 2:SUITE 3100
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-2105
Practice Address - Country:US
Practice Address - Phone:602-867-8644
Practice Address - Fax:602-795-5698
Is Sole Proprietor?:No
Enumeration Date:2005-06-30
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2309363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ970013946OtherRAILROAD MEDICARE
AZ495920Medicaid
AZ1Z5306OtherHEALTHNET
AZ970013946OtherRAILROAD MEDICARE
Z142073Medicare PIN
AZR09718Medicare UPIN