Provider Demographics
NPI:1093954687
Name:CARLSON, BRIAN G (MSN)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:G
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MSN
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Mailing Address - Street 1:9200 W WISCONSIN AVENUE
Mailing Address - Street 2:DEPARTMENT OF RADIOLOGY
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53226-3522
Mailing Address - Country:US
Mailing Address - Phone:414-805-3750
Mailing Address - Fax:414-259-9290
Practice Address - Street 1:9200 W WISCONSIN AVENUE
Practice Address - Street 2:DEPARTMENT OF RADIOLOGY
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53226-3522
Practice Address - Country:US
Practice Address - Phone:414-805-3750
Practice Address - Fax:414-259-9290
Is Sole Proprietor?:No
Enumeration Date:2009-02-05
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI3641-033363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1093954687Medicaid