Provider Demographics
NPI:1811949654
Name:CARLSON, JOHN ROBERT (PT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:CARLSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2174 SW WARBLER WAY
Mailing Address - Street 2:
Mailing Address - City:BREMERTON
Mailing Address - State:WA
Mailing Address - Zip Code:98312-8204
Mailing Address - Country:US
Mailing Address - Phone:360-509-7165
Mailing Address - Fax:
Practice Address - Street 1:1880 POTTERY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:PORT ORCHARD
Practice Address - State:WA
Practice Address - Zip Code:98366
Practice Address - Country:US
Practice Address - Phone:360-895-9090
Practice Address - Fax:360-895-9089
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00003990225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0150494OtherL L
WA8339343Medicaid
P00129558OtherRAILROAD MEDICARE
WA8339343Medicaid