Provider Demographics
NPI:1205066388
Name:CARLSON, ALYSSA SNOW (MD)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:SNOW
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALYSSA
Other - Middle Name:SNOW
Other - Last Name:GERRITSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 9049
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-9049
Mailing Address - Country:US
Mailing Address - Phone:303-415-8900
Mailing Address - Fax:303-443-6476
Practice Address - Street 1:1645 BROADWAY
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80302-6218
Practice Address - Country:US
Practice Address - Phone:303-415-8900
Practice Address - Fax:303-443-6476
Is Sole Proprietor?:No
Enumeration Date:2009-07-22
Last Update Date:2023-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0050026207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO10202218Medicaid
CO10202218Medicaid