Provider Demographics
NPI:1700560471
Name:CARLSON, TATYANA YGNACIA (IDMT)
Entity Type:Individual
Prefix:
First Name:TATYANA
Middle Name:YGNACIA
Last Name:CARLSON
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3280 MITCHELL BLVD
Mailing Address - Street 2:
Mailing Address - City:MOODY AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31699-1500
Mailing Address - Country:US
Mailing Address - Phone:229-257-2778
Mailing Address - Fax:
Practice Address - Street 1:710 VANGUARD WAY
Practice Address - Street 2:
Practice Address - City:MOODY AFB
Practice Address - State:GA
Practice Address - Zip Code:31699-8704
Practice Address - Country:US
Practice Address - Phone:229-257-2778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-13
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians