Provider Demographics
NPI:1316168966
Name:CARLSON, CHRISTOPHER LANCE (MD)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:LANCE
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7319 N NEVADA AVE
Mailing Address - Street 2:
Mailing Address - City:PARKVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:64152-1191
Mailing Address - Country:US
Mailing Address - Phone:636-346-4619
Mailing Address - Fax:
Practice Address - Street 1:100 N CLAYVIEW DR
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-1115
Practice Address - Country:US
Practice Address - Phone:816-781-9222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-01
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010010433207P00000X
KS04-34384207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1316168966Medicaid
MOR86000039OtherMO MEDICARE