Provider Demographics
NPI:1467665315
Name:CARLSON, HEATHER R (DO)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:R
Last Name:CARLSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:RAE
Other - Last Name:HIESTERMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 8674
Mailing Address - Street 2:1230 E. MAIN STREET MANKATO CLINIC, LTD
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1230 E. MAIN STREET
Practice Address - Street 2:MANKATO CLINIC AT MAIN STREET
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56002-8674
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101016536207V00000X
MN52425207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN160003081Medicare PIN