Provider Demographics
NPI:1386788859
Name:CARLSON, DANIEL MIN (LAC)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:MIN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2641 2ND ST
Mailing Address - Street 2:4-R
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11102-4192
Mailing Address - Country:US
Mailing Address - Phone:503-780-0272
Mailing Address - Fax:
Practice Address - Street 1:2641 2ND ST
Practice Address - Street 2:4-R
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11102-4192
Practice Address - Country:US
Practice Address - Phone:503-780-0272
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-17
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC00589171100000X
NY22 636 407163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No163W00000XNursing Service ProvidersRegistered Nurse