Basic Information
| Provider Information | |||||||||
| NPI: | 1760426761 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | PETER | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 670 9TH ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | ARCATA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955216248 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078268633 | ||||||||
| FaxNumber: | 7078268638 | ||||||||
| Practice Location | |||||||||
| Address1: | 1644 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | MCKINLEYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 955194342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7078393068 | ||||||||
| FaxNumber: | 7078393827 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2006 | ||||||||
| LastUpdateDate: | 03/01/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | G32605 | CA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207Q00000X | G32605 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G326050 | 05 | CA | MEDICAID |