Provider Demographics
NPI:1700820883
Name:CARLSON, NICOLE ANNE BEMMELS (MSPA)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNE BEMMELS
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MSPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6500 EXCELSIOR BLVD.
Mailing Address - Street 2:PARK NICOLLET HEART AND VASCULAR CENTER
Mailing Address - City:ST. LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55426
Mailing Address - Country:US
Mailing Address - Phone:612-624-0123
Mailing Address - Fax:
Practice Address - Street 1:6500 EXCELSIOR
Practice Address - Street 2:PARK NICOLLET HEART AND VASCULAR CENTER
Practice Address - City:ST. LUOIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55426
Practice Address - Country:US
Practice Address - Phone:612-423-9088
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9899363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41995800Medicaid
MN01-06279OtherMEDICA PRIMARY
MN2230947OtherARAZ
MN616R8BEOtherBCBS
MN01-19215OtherMEDICA CHOICE
MN132339OtherUCARE
MNB018OtherCHAMPUS/TRIWEST
MN916427800Medicaid
MN1042013OtherPREFERRED ONE
MNHP46702OtherHEALTHPARTNERS
MN1042013OtherPREFERRED ONE
MN132339OtherUCARE
MNP00216900Medicare ID - Type UnspecifiedRAILROAD MEDICARE
MN916427800Medicaid