Provider Demographics
NPI:1235959529
Name:CARLSON, MAXWEL DAVID
Entity type:Individual
Prefix:
First Name:MAXWEL
Middle Name:DAVID
Last Name:CARLSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 RIVERSIDE ST APT 3-1
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-2666
Mailing Address - Country:US
Mailing Address - Phone:320-266-4007
Mailing Address - Fax:
Practice Address - Street 1:20 RIVERSIDE ST APT 3-1
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:MA
Practice Address - Zip Code:02472-2666
Practice Address - Country:US
Practice Address - Phone:320-266-4007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-12
Last Update Date:2024-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2381302163W00000X
MAAG09240067363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse