Provider Demographics
NPI:1518192954
Name:CARLSON, CARISSA MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:CARISSA
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CROIX FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:54024-4117
Mailing Address - Country:US
Mailing Address - Phone:715-483-3221
Mailing Address - Fax:715-483-0507
Practice Address - Street 1:235 E STATE ST
Practice Address - Street 2:
Practice Address - City:SAINT CROIX FALLS
Practice Address - State:WI
Practice Address - Zip Code:54024-4117
Practice Address - Country:US
Practice Address - Phone:715-483-3221
Practice Address - Fax:715-483-0507
Is Sole Proprietor?:No
Enumeration Date:2009-05-28
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN363A00000X
WI2444363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant