Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RG0300X | Geriatric Medicine | 1009320 | CA |
NPI | 1134446875 |
---|---|
Provider Name | Miss Charlotte Mary Carlson |
First Address | Santa Rosa, CA 95405-7815 |
Second Address | Santa Rosa, CA 95405-7815 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/04/2010 |
Last Update Date | 29/01/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
A119269 | STATE MEDICAL LICENSE (01) | CA |