Basic Information
| Provider Information | |||||||||
| NPI: | 1366751059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARSON | ||||||||
| FirstName: | VERONICA | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | GNP-BG | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | VERONICA | ||||||||
| OtherMiddleName: | LYNN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2965 E TARPON DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | MERIDIAN | ||||||||
| State: | ID | ||||||||
| PostalCode: | 836429007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2082879420 | ||||||||
| FaxNumber: | 2082879426 | ||||||||
| Practice Location | |||||||||
| Address1: | 4195 WESTBERG RD APT 436 | ||||||||
| Address2: | |||||||||
| City: | HERMANTOWN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558113888 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7015164637 | ||||||||
| FaxNumber: | 8776511381 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2010 | ||||||||
| LastUpdateDate: | 07/15/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 1294 | MN | N | Allopathic & Osteopathic Physicians | Hospitalist | 363LG0600X | R-175893-7 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.