MEDICARE: TRACEE JEAN MARTIN KARLSON

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	225100000X	Physical Therapist	PT00007810	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0177730	OTHER	WA	LABOR AND INDUSTRIES

General Provider Information

NPI Number	:	1982690467
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACEE JEAN MARTIN KARLSON

Provider Business Mailing Address
First Line	:	6028 TIGER TAIL DR SW
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98512-2141
Country	:	US
Telephone Number	:	360-584-4556
Fax Number	:	360-251-0011

Provider Business Practice Location Address
First Line	:	1802 BLACK LAKE BLVD SW STE 103
Second Line	:
City	:	OLYMPIA
State	:	WA
Zip	:	98512-5634
Country	:	US
Telephone Number	:	360-584-4556
Fax Number	:	360-251-0011

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

Provider Enumeration Date	:	09/21/2005
Last Update Date	:	01/09/2023

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