Healthcare Provider Details

I. General information

NPI: 1194395582
Provider Name (Legal Business Name): BREANNA KAY CARLSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4212 N 16TH ST
PHOENIX AZ
85016-5319
US

IV. Provider business mailing address

PO BOX 95460
CLEVELAND OH
44101-0033
US

V. Phone/Fax

Practice location:
  • Phone: 602-263-1200
  • Fax: 602-263-1619
Mailing address:
  • Phone: 602-581-6076
  • Fax: 602-263-1619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number8116
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: