Provider Demographics
NPI:1427061902
Name:CARLSON, CHRISTOPHER RYAN (RPT)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:RYAN
Last Name:CARLSON
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-5699 KOPIKO ST
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-3651
Mailing Address - Country:US
Mailing Address - Phone:808-329-7744
Mailing Address - Fax:808-334-1608
Practice Address - Street 1:75-5699 KOPIKO ST
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-3651
Practice Address - Country:US
Practice Address - Phone:808-329-7744
Practice Address - Fax:808-334-1608
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIPT 2423225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI55951002Medicaid
HIH103159Medicare PIN