Provider Demographics
NPI:1619930351
Name:CARLSON-AMIRAYAN, JULIE RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:RENEE
Last Name:CARLSON-AMIRAYAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JULIE
Other - Middle Name:RENEE
Other - Last Name:CARLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHYSICIAN ASSISTANT
Mailing Address - Street 1:600 W 98TH ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-4773
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 W 98TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-4773
Practice Address - Country:US
Practice Address - Phone:952-885-6060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2008-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9556363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS62998Medicare UPIN