Basic Information
| Provider Information | |||||||||
| NPI: | 1740206473 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | PAMELA | ||||||||
| MiddleName: | JEANNE | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10B ABS RD | ||||||||
| Address2: | |||||||||
| City: | SANTA FE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875067906 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492356080 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1010 SPRUCE ST | ||||||||
| Address2: | |||||||||
| City: | ESPANOLA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 875322724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057537111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | R53755 | NM | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 73839370 | 05 | NM | MEDICAID |