Provider Demographics
NPI:1699428136
Name:IGWACHO, CARLSON (RN)
Entity type:Individual
Prefix:MR
First Name:CARLSON
Middle Name:
Last Name:IGWACHO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2104 PINEY BRANCH CIR APT 401
Mailing Address - Street 2:
Mailing Address - City:HANOVER
Mailing Address - State:MD
Mailing Address - Zip Code:21076-1836
Mailing Address - Country:US
Mailing Address - Phone:240-350-2508
Mailing Address - Fax:
Practice Address - Street 1:2104 PINEY BRANCH CIR APT 401
Practice Address - Street 2:
Practice Address - City:HANOVER
Practice Address - State:MD
Practice Address - Zip Code:21076-1836
Practice Address - Country:US
Practice Address - Phone:240-350-2508
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR214040163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse