Provider Demographics
NPI:1083824031
Name:CARLSON, MISTY LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:MISTY
Middle Name:LYNN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13014 NW CORSO LN
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-3709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:707 SW GAINES ST
Practice Address - Street 2:CDRC-P
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2901
Practice Address - Country:US
Practice Address - Phone:503-494-8702
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL161952080P0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0202XAllopathic & Osteopathic PhysiciansPediatricsPediatric Cardiology