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General NPI Number Information
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NPI Number | 1083824031
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Entity Type | Individual
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Provider Name | MISTY LYNN CARLSON M.D.
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Gender | Female
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Dates
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Enumeration Date | 05/22/2007
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Last Update Date | 10/02/2024
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Provider Practice Location Address
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Address Line | 3377 RIVERBEND DR
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City | SPRINGFIELD
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State | OR
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Zip | 97477-8803
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Country | US
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Telephone | 541-222-6160
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Fax | 541-222-6166
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Provider Business Mailing Address
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Address Line | 13014 NW CORSO LN
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City | PORTLAND
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State | OR
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Zip | 97229-3709
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080P0202X
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Taxonomy Name | Pediatric Cardiology Physician
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License Number | LL16195
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 2080P0202X
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Taxonomy Name | Pediatric Cardiology Physician
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License Number | MD126085
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License Number State | OR
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