Provider Demographics
NPI:1982980082
Name:CARLSON, TREVOR E (PT)
Entity Type:Individual
Prefix:
First Name:TREVOR
Middle Name:E
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 1:2306 DEAN ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95501-3209
Mailing Address - Country:US
Mailing Address - Phone:707-443-8354
Mailing Address - Fax:707-443-8628
Practice Address - Street 1:1585 HEARTWOOD DR STE H
Practice Address - Street 2:
Practice Address - City:MCKINLEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95519-3993
Practice Address - Country:US
Practice Address - Phone:707-839-1802
Practice Address - Fax:707-839-3507
Is Sole Proprietor?:No
Enumeration Date:2011-11-02
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT38366174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38366OtherLICENSE
CACH2219OtherRR MEDICARE #
CAZZZ18018ZMedicare PIN
CA38366OtherLICENSE
CAZZZ26450ZMedicare PIN