Provider Demographics
NPI:1598056426
Name:CARLSON, CHARLOTTE SANTIAGO
Entity Type:Individual
Prefix:
First Name:CHARLOTTE
Middle Name:SANTIAGO
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24035 OCEAN AVE
Mailing Address - Street 2:#18
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-6433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1850 REDONDO AVE
Practice Address - Street 2:SUITE 108
Practice Address - City:SIGNAL HILL
Practice Address - State:CA
Practice Address - Zip Code:90755-1251
Practice Address - Country:US
Practice Address - Phone:562-498-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical