Healthcare Provider Details

I. General information

NPI: 1780694620
Provider Name (Legal Business Name): CARSON MEDICAL GROUP PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1946 OLD HOT SPRINGS RD
CARSON CITY NV
89706-0674
US

IV. Provider business mailing address

1946 OLD HOT SPRINGS RD
CARSON CITY NV
89706-0674
US

V. Phone/Fax

Practice location:
  • Phone: 775-283-5050
  • Fax:
Mailing address:
  • Phone: 775-283-5050
  • Fax: 775-882-2382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: LAURIE CAMPER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 775-883-5555