Provider Demographics
NPI:1407442700
Name:WADSWORTH, CARLOS M
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:M
Last Name:WADSWORTH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8293 39TH ST NE
Mailing Address - Street 2:
Mailing Address - City:SAINT MICHAEL
Mailing Address - State:ND
Mailing Address - Zip Code:58370-9031
Mailing Address - Country:US
Mailing Address - Phone:701-425-5798
Mailing Address - Fax:
Practice Address - Street 1:3889 74 TH AVE N.E APT. 110
Practice Address - Street 2:
Practice Address - City:FT. TOTTEN
Practice Address - State:ND
Practice Address - Zip Code:58335
Practice Address - Country:US
Practice Address - Phone:701-230-4641
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
3747P1801X
NDR49594163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant