Provider Demographics
NPI:1669869574
Name:VAN SANFORD, CARSON
Entity type:Individual
Prefix:
First Name:CARSON
Middle Name:
Last Name:VAN SANFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3360
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97208-3360
Mailing Address - Country:US
Mailing Address - Phone:866-747-2455
Mailing Address - Fax:
Practice Address - Street 1:1321 COLBY AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1665
Practice Address - Country:US
Practice Address - Phone:425-261-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT1046812084N0400X
IDMC-12312084N0400X
ORMD2084812084N0400X
AK1867402084N0400X
CAA1775022084N0400X
TXT70692084N0400X
NMTM2022-04102084N0400X
WAMD609422202084V0102X, 2084N0400X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program