Healthcare Provider Details

I. General information

NPI: 1386810810
Provider Name (Legal Business Name): SUSAN CARSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2008
Last Update Date: 05/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 W SUNSET BLVD MS #54
LOS ANGELES CA
90027-6062
US

IV. Provider business mailing address

3701 WILSHIRE BLVD SUITE 600
LOS ANGELES CA
90010-2814
US

V. Phone/Fax

Practice location:
  • Phone: 323-361-2121
  • Fax: 323-361-7128
Mailing address:
  • Phone: 323-361-3550
  • Fax: 323-361-8052

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number12739
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number544439
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: