Provider Demographics
NPI:1912008970
Name:CARLSON, CONNIE JANEL (CRNA)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:JANEL
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:JANEL
Other - Last Name:MAGNUSSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2700 CLAY EDWARDS DR STE 240
Mailing Address - Street 2:
Mailing Address - City:NORTH KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64116-3254
Mailing Address - Country:US
Mailing Address - Phone:816-691-2021
Mailing Address - Fax:816-346-7690
Practice Address - Street 1:2700 CLAY EDWARDS DR STE 240
Practice Address - Street 2:
Practice Address - City:NORTH KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64116-3254
Practice Address - Country:US
Practice Address - Phone:816-691-2021
Practice Address - Fax:816-346-7690
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2021-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005022431367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1912008970Medicaid
KS200640000AMedicaid
MO917601700Medicaid
MOP00835587OtherRR MEDICARE
MOK98000004Medicare PIN
Q60964Medicare UPIN
MO917601700Medicaid