Healthcare Provider Details

I. General information

NPI: 1427699230
Provider Name (Legal Business Name): KEITH CARLSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2019
Last Update Date: 10/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W MINERAL KING AVE
VISALIA CA
93291-6237
US

IV. Provider business mailing address

PO BOX 6339
VISALIA CA
93290-6339
US

V. Phone/Fax

Practice location:
  • Phone: 775-722-7245
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number95001188
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: