Provider Demographics
NPI:1982368866
Name:CARLSON, DAVID WALTER JR (CRNA)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WALTER
Last Name:CARLSON
Suffix:JR
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44405 BAYVIEW AVE APT 33106
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-7295
Mailing Address - Country:US
Mailing Address - Phone:586-212-0300
Mailing Address - Fax:
Practice Address - Street 1:3601 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6712
Practice Address - Country:US
Practice Address - Phone:248-898-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-26
Last Update Date:2022-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704318026163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse