Provider Demographics
NPI:1861864860
Name:CARLSON, THERESA (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4708 ALLIANCE BLVD STE 600
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75093-5368
Mailing Address - Country:US
Mailing Address - Phone:469-467-0011
Mailing Address - Fax:469-467-4923
Practice Address - Street 1:4708 ALLIANCE BLVD STE 600
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5368
Practice Address - Country:US
Practice Address - Phone:469-467-0011
Practice Address - Fax:469-467-4923
Is Sole Proprietor?:No
Enumeration Date:2015-10-29
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP129474363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX360325002Medicaid
TX360325001Medicaid