Provider Demographics
NPI:1306814108
Name:CARLSON, BETH (CNM)
Entity Type:Individual
Prefix:
First Name:BETH
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5350 EASTERN AVE.
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2709
Mailing Address - Country:US
Mailing Address - Phone:563-355-1853
Mailing Address - Fax:563-359-1512
Practice Address - Street 1:5350 EASTERN AVE.
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2709
Practice Address - Country:US
Practice Address - Phone:563-355-1853
Practice Address - Fax:563-359-1512
Is Sole Proprietor?:No
Enumeration Date:2006-03-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAB107428367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAP74218Medicare UPIN