Basic Information
| Provider Information | |||||||||
| NPI: | 1245317486 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | KAREN | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | ARNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 3360 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972083360 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604134200 | ||||||||
| FaxNumber: | 3604134225 | ||||||||
| Practice Location | |||||||||
| Address1: | 273 SUSSEX AVE E | ||||||||
| Address2: | |||||||||
| City: | TENINO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985899359 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3602645665 | ||||||||
| FaxNumber: | 3602645666 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | AP30004220 | WA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 9635285 | 05 | WA | MEDICAID |