Provider Demographics
NPI:1679312144
Name:CARLSON, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 RIVER TERRACE CT APT 105
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414
Mailing Address - Country:US
Mailing Address - Phone:507-261-6788
Mailing Address - Fax:
Practice Address - Street 1:2211 RIVERSIDE AVE S CAMPUS BOX 149
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454
Practice Address - Country:US
Practice Address - Phone:612-330-1388
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant