Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | MD00034699 | WA |
NPI | 1003841537 |
---|---|
Provider Name | Glen Carlson |
First Address | Silverdale, WA 98383-7397 |
Second Address | Bremerton, WA 98310-4229 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/07/2006 |
Last Update Date | 21/05/2008 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
8227183 | (05) | WA |
8460370 | (05) | WA |
G03810 | (02) | WA |