Basic Information
| Provider Information | |||||||||
| NPI: | 1144315953 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | VICKI | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3998 FAIR RIDGE DR | ||||||||
| Address2: | STE 300 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220332921 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7037669737 | ||||||||
| FaxNumber: | 7037669725 | ||||||||
| Practice Location | |||||||||
| Address1: | 3600 JOSEPH SIEWICK DR | ||||||||
| Address2: | |||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220331709 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7033913600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/04/2006 | ||||||||
| LastUpdateDate: | 04/23/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 0024166330 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 301907 | 01 | VA | AMERIGROUP | OTHER | K142-0002 | 01 | DC | CAREFIRST | OTHER | 139180 | 01 | VA | ANTHEM | OTHER | 484645 | 01 | VA | NCPPO | OTHER | 1144315953 | 05 | VA | MEDICAID | P00313213 | 01 | VA | RAILROAD MEDICARE | OTHER |