Provider Demographics
NPI:1396917977
Name:NICOLE CARLSON MD LLC
Entity type:Organization
Organization Name:NICOLE CARLSON MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:CARLSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:724-654-3222
Mailing Address - Street 1:219 WEST FAIRMONT AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW CASTLE
Mailing Address - State:PA
Mailing Address - Zip Code:16105
Mailing Address - Country:US
Mailing Address - Phone:724-654-3222
Mailing Address - Fax:
Practice Address - Street 1:219 WEST FAIRMONT AVENUE
Practice Address - Street 2:
Practice Address - City:NEW CASTLE
Practice Address - State:PA
Practice Address - Zip Code:16105
Practice Address - Country:US
Practice Address - Phone:724-654-3222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD430168207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty