Provider Demographics
NPI:1174311674
Name:CARSON, WILLIE SR
Entity type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:
Last Name:CARSON
Suffix:SR
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 1:2730 LOIS ST # 1
Mailing Address - Street 2:
Mailing Address - City:PORTAGE
Mailing Address - State:IN
Mailing Address - Zip Code:46368-3532
Mailing Address - Country:US
Mailing Address - Phone:219-654-3019
Mailing Address - Fax:219-406-0162
Practice Address - Street 1:2730 LOIS ST # 1
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:IN
Practice Address - Zip Code:46368-3532
Practice Address - Country:US
Practice Address - Phone:219-654-3019
Practice Address - Fax:219-406-0162
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-25
Last Update Date:2025-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant