Provider Demographics
NPI:1003818758
Name:CARLSON, TIMOTHY A (CRNP)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:A
Last Name:CARLSON
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2234 PERKIOMEN AVE
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19606-1830
Mailing Address - Country:US
Mailing Address - Phone:610-370-2511
Mailing Address - Fax:610-370-9348
Practice Address - Street 1:2234 PERKIOMEN AVE
Practice Address - Street 2:
Practice Address - City:READING
Practice Address - State:PA
Practice Address - Zip Code:19606-1830
Practice Address - Country:US
Practice Address - Phone:610-370-2511
Practice Address - Fax:610-370-9348
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2014-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP005613B363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA007706668Medicaid
PA007706668Medicaid
PA589207Medicare UPIN