Provider Demographics
NPI:1497947634
Name:CARLSON, NICHOLAS ELY (ATC, AT/L)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ELY
Last Name:CARLSON
Suffix:
Gender:M
Credentials:ATC, AT/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5420 W BARNES RD
Mailing Address - Street 2:#E334
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99208-7027
Mailing Address - Country:US
Mailing Address - Phone:509-995-1573
Mailing Address - Fax:
Practice Address - Street 1:505 E 3RD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1426
Practice Address - Country:US
Practice Address - Phone:509-995-1573
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer