Provider Demographics
NPI:1730216326
Name:CARLSON, LEANNE RENEE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:LEANNE
Middle Name:RENEE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6068
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68506-0068
Mailing Address - Country:US
Mailing Address - Phone:402-484-9009
Mailing Address - Fax:
Practice Address - Street 1:1710 S 70TH ST
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68506-1676
Practice Address - Country:US
Practice Address - Phone:402-484-9009
Practice Address - Fax:402-483-4223
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1302363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47065843713Medicaid
NE47065843713Medicaid