Provider Demographics
NPI:1689169989
Name:CARSON, GRACE (MD)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:CARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4407 CHATSWORTH ST N
Mailing Address - Street 2:
Mailing Address - City:SHOREVIEW
Mailing Address - State:MN
Mailing Address - Zip Code:55126-2251
Mailing Address - Country:US
Mailing Address - Phone:701-429-1760
Mailing Address - Fax:
Practice Address - Street 1:4465 WHITE BEAR PKWY
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-7623
Practice Address - Country:US
Practice Address - Phone:651-653-0062
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-28
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2018019964207R00000X
MN72400207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty