Provider Demographics
NPI:1962472035
Name:CARLSON, MARTHA ALEISA (WHNP)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:ALEISA
Last Name:CARLSON
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:580 NEW WAVERLY PL
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CARY
Mailing Address - State:NC
Mailing Address - Zip Code:27518-7406
Mailing Address - Country:US
Mailing Address - Phone:919-858-8360
Mailing Address - Fax:919-858-8408
Practice Address - Street 1:580 NEW WAVERLY PL
Practice Address - Street 2:SUITE 120
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7406
Practice Address - Country:US
Practice Address - Phone:919-858-8360
Practice Address - Fax:919-858-8408
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO99045367A00000X
NC5007916363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCA658010OtherBLUE CROSS BLUE SHIELD
CO30487749Medicaid
CO30487749Medicaid
COC395328Medicare PIN
COP28761Medicare UPIN