Provider Demographics
NPI:1477035459
Name:CARLSON, RYAN
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:CARLSON
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 1:103 SW WINSTED LN STE 25
Mailing Address - Street 2:
Mailing Address - City:BENTONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72713-6203
Mailing Address - Country:US
Mailing Address - Phone:479-595-8022
Mailing Address - Fax:
Practice Address - Street 1:103 SW WINSTED LN STE 25
Practice Address - Street 2:
Practice Address - City:BENTONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72713-6203
Practice Address - Country:US
Practice Address - Phone:479-595-8022
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR16200111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor