Provider Demographics
NPI:1356596415
Name:CARLSON, RENEE MARIE (CRNA)
Entity type:Individual
Prefix:MISS
First Name:RENEE
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:425 PINE RIDGE BLVD STE 211
Mailing Address - Street 2:
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4123
Mailing Address - Country:US
Mailing Address - Phone:715-845-5505
Mailing Address - Fax:715-848-2884
Practice Address - Street 1:425 PINE RIDGE BLVD STE 211
Practice Address - Street 2:
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4123
Practice Address - Country:US
Practice Address - Phone:715-845-5505
Practice Address - Fax:715-848-2884
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2009-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI148002030367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1356596415Medicaid
WI213050061OtherWPS MEDICARE