Provider Demographics
NPI:1801523923
Name:CARSON, KEYANNA J
Entity type:Individual
Prefix:
First Name:KEYANNA
Middle Name:J
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 1:4142 MESA VERDE AVE NE APT 4
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87110-7789
Mailing Address - Country:US
Mailing Address - Phone:505-850-4212
Mailing Address - Fax:
Practice Address - Street 1:3150 CARLISLE BLVD NE STE 105
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87110-1680
Practice Address - Country:US
Practice Address - Phone:505-633-8173
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-08
Last Update Date:2022-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist