Provider Demographics
NPI:1922547314
Name:CARLSON, DEREK JOHN (RN)
Entity Type:Individual
Prefix:MR
First Name:DEREK
Middle Name:JOHN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2512 STATE ROUTE 5 AND 20
Mailing Address - Street 2:
Mailing Address - City:STANLEY
Mailing Address - State:NY
Mailing Address - Zip Code:14561-9521
Mailing Address - Country:US
Mailing Address - Phone:315-759-0476
Mailing Address - Fax:
Practice Address - Street 1:35 NORTH ST
Practice Address - Street 2:
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-1075
Practice Address - Country:US
Practice Address - Phone:585-394-0530
Practice Address - Fax:585-394-3872
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-17
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY703439-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse