Provider Demographics
NPI:1649628157
Name:CARLSON, SHAWNN (MA 60593496)
Entity type:Individual
Prefix:
First Name:SHAWNN
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MA 60593496
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 E 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-3539
Mailing Address - Country:US
Mailing Address - Phone:208-255-9842
Mailing Address - Fax:
Practice Address - Street 1:1611 E 13TH AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-3539
Practice Address - Country:US
Practice Address - Phone:208-255-9842
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-25
Last Update Date:2016-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60593496174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist