Provider Demographics
NPI:1679575815
Name:CARLSON, DAVID A (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:A
Last Name:CARLSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1720 LOUISIANA BLVD NE
Mailing Address - Street 2:STE 401
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7020
Mailing Address - Country:US
Mailing Address - Phone:505-260-4300
Mailing Address - Fax:505-260-4371
Practice Address - Street 1:1100 CENTRAL AVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4930
Practice Address - Country:US
Practice Address - Phone:505-841-1234
Practice Address - Fax:505-841-1956
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR51211367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM84746Medicaid
AZ835069Medicaid
NM942054OtherPRONET / AETNA
NMNM006892OtherBLUE CROSS BLUE SHIELD
NM91575257Medicaid
NM91575257Medicaid
NM344411202Medicare ID - Type UnspecifiedMEDICARE