Provider Demographics
NPI:1134222797
Name:CARLSON, GLENICE M (PAC)
Entity type:Individual
Prefix:MRS
First Name:GLENICE
Middle Name:M
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2320 124 AVE S
Mailing Address - Street 2:
Mailing Address - City:HORACE
Mailing Address - State:ND
Mailing Address - Zip Code:58047
Mailing Address - Country:US
Mailing Address - Phone:701-476-7239
Mailing Address - Fax:701-280-5798
Practice Address - Street 1:510 4TH ST S
Practice Address - Street 2:PRAIRIE ST JOHNS
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103
Practice Address - Country:US
Practice Address - Phone:701-476-7239
Practice Address - Fax:701-280-5798
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND21470Medicare ID - Type Unspecified
R92470Medicare UPIN