Provider Demographics
NPI:1679322325
Name:MCINNIS, CARSON (DPT)
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:MCINNIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13555 SE 36TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98006-1456
Mailing Address - Country:US
Mailing Address - Phone:866-839-6979
Mailing Address - Fax:
Practice Address - Street 1:13555 SE 36TH ST STE 100
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98006-1456
Practice Address - Country:US
Practice Address - Phone:866-839-6979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-15
Last Update Date:2024-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT61309985225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist