MEDICARE: RUSSELL V. K. CARSON

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	363LF0000X	Family Nurse Practitioner	AP04417	LA

General Provider Information

NPI Number	:	1851302996
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RUSSELL V. K. CARSON

Provider Business Mailing Address
First Line	:	PO BOX 772
Second Line	:	MINUTECLINIC CREDENTIALING
City	:	WOONSOCKET
State	:	RI
Zip	:	02895-0784
Country	:	US
Telephone Number	:	401-770-1669
Fax Number	:	401-652-9787

Provider Business Practice Location Address
First Line	:	2915 HIGHWAY 190
Second Line	:
City	:	MANDEVILLE
State	:	LA
Zip	:	70471-3298
Country	:	US
Telephone Number	:	985-626-8106
Fax Number	:

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

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	09/27/2013

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