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General NPI Number Information
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NPI Number | 1215385794
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Entity Type | Organization
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Legal Business Name | R LYNN CARLSON MD PC MEDICENTER
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Dates
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Enumeration Date | 05/25/2016
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Last Update Date | 05/01/2018
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Provider Practice Location Address
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Address Line | 43783 KENAI SPUR HWY
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City | NIKISKI
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State | AK
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Zip | 99611-9708
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Country | US
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Telephone | 907-283-9116
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Fax | 907-283-9122
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Provider Business Mailing Address
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Address Line | PO BOX 240
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City | KENAI
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State | AK
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Zip | 99611-0240
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Country | US
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Telephone | 907-283-9118
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Fax |
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Authorized Official
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Title or Position | EXECUTIVE DIRECTOR
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Name | JOSEPH A HURLEY
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Credential | BM, PFS
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Telephone | 360-771-7458
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PADA895
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License Number State | AK
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