Provider Demographics
NPI:1093346918
Name:CARSON, AMY (LAC)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:CARSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 WILBUR AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-2028
Mailing Address - Country:US
Mailing Address - Phone:714-249-3713
Mailing Address - Fax:
Practice Address - Street 1:1050 WILBUR AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-2028
Practice Address - Country:US
Practice Address - Phone:714-249-3713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC18697171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD1813540Medicaid
CAD1813540OtherDMV