Healthcare Provider Details

I. General information

NPI: 1740206473
Provider Name (Legal Business Name): PAMELA JEANNE CARLSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1010 SPRUCE ST
ESPANOLA NM
87532-2724
US

IV. Provider business mailing address

10B ABS RD
SANTA FE NM
87506-7906
US

V. Phone/Fax

Practice location:
  • Phone: 505-753-7111
  • Fax:
Mailing address:
  • Phone: 949-235-6080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR53755
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: