1194007534 NPI number — MRS. ASHLEY RYAN CARLSON RD, LD

Table of content: MARIO PARY DMD (NPI 1386711620)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194007534 NPI number — MRS. ASHLEY RYAN CARLSON RD, LD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CARLSON
Provider First Name:
ASHLEY
Provider Middle Name:
RYAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RD, LD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194007534
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/11/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
MEDDAC, 11050 MOUNT BELVEDERE BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT DRUM
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-772-4759
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9040 FITZSIMMONS DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOINT BASE LEWIS MCCHORD
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98431-1000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
253-968-1936
Provider Business Practice Location Address Fax Number:
253-968-0567
Provider Enumeration Date:
09/12/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  LD004015 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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