MEDICARE: CARSON WATARU ERCANBRACK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1235968470
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARSON WATARU ERCANBRACK

Provider Business Mailing Address
First Line	:	3700 OLD CANTRELL RD APT 412
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72202-1967
Country	:	US
Telephone Number	:	480-389-7419
Fax Number	:

Provider Business Practice Location Address
First Line	:	3700 OLD CANTRELL RD APT 412
Second Line	:
City	:	LITTLE ROCK
State	:	AR
Zip	:	72202-1967
Country	:	US
Telephone Number	:	480-389-7419
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/27/2024
Last Update Date	:	07/27/2024

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