Provider Demographics
NPI:1700638806
Name:CARSON, ADRA
Entity Type:Individual
Prefix:
First Name:ADRA
Middle Name:
Last Name:CARSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13705 PILLAR ROCK ST
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:ID
Mailing Address - Zip Code:83607-5550
Mailing Address - Country:US
Mailing Address - Phone:208-880-4512
Mailing Address - Fax:
Practice Address - Street 1:6305 W OVERLAND RD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-3029
Practice Address - Country:US
Practice Address - Phone:208-605-3663
Practice Address - Fax:208-550-3241
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-02
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No172V00000XOther Service ProvidersCommunity Health Worker