Basic Information
| Provider Information | |||||||||
| NPI: | 1538401948 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARSTENSEN | ||||||||
| FirstName: | KARISSA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2478 13TH ST. SE | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973022546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033622481 | ||||||||
| FaxNumber: | 5033758700 | ||||||||
| Practice Location | |||||||||
| Address1: | MSC 10 5590 | ||||||||
| Address2: | 1 UNIVERSITY OF NEW MEXICO | ||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871310001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052725551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2013 | ||||||||
| LastUpdateDate: | 09/19/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | RS2013-0348 | NM | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | MD176951 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 500707979 | 05 | OR | MEDICAID |