Provider Demographics
NPI:1689653826
Name:CARLSON, SHANNON (CRNA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 67000
Mailing Address - Street 2:DEPT 203401
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48267-0002
Mailing Address - Country:US
Mailing Address - Phone:952-442-9770
Mailing Address - Fax:
Practice Address - Street 1:1 WILLIAM CARLS DR
Practice Address - Street 2:
Practice Address - City:COMMERCE TWP
Practice Address - State:MI
Practice Address - Zip Code:48382-2201
Practice Address - Country:US
Practice Address - Phone:248-937-3307
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704217760367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MISC217760OtherBLUE CROSS OF MI
MISC217760OtherBLUE CROSS OF MI
MIP00229431Medicare ID - Type UnspecifiedRAILROAD MEDICARE