Provider Demographics
NPI:1144315953
Name:CARLSON, VICKI J (CRNA)
Entity type:Individual
Prefix:MS
First Name:VICKI
Middle Name:J
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3998 FAIR RIDGE DR
Mailing Address - Street 2:STE 300
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033-2921
Mailing Address - Country:US
Mailing Address - Phone:703-766-9737
Mailing Address - Fax:703-766-9725
Practice Address - Street 1:3600 JOSEPH SIEWICK DR
Practice Address - Street 2:
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22033-1709
Practice Address - Country:US
Practice Address - Phone:703-391-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2015-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166330367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA301907OtherAMERIGROUP
DCK142-0002OtherCAREFIRST
VA139180OtherANTHEM
VA484645OtherNCPPO
VA1144315953Medicaid
VAP00313213OtherRAILROAD MEDICARE
VA139180OtherANTHEM
DC016127F89Medicare PIN