Provider Demographics
NPI:1720221963
Name:CARLSON, RYAN MATTHEW (MD)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MATTHEW
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:640 JACKSON ST
Mailing Address - Street 2:MS 11502V
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2502
Mailing Address - Country:US
Mailing Address - Phone:651-254-7980
Mailing Address - Fax:651-254-7990
Practice Address - Street 1:401 PHALEN BLVD - MS 41104A
Practice Address - Street 2:HEALTHPARTNERS SPECIALTY CENTER 401
Practice Address - City:ST. PAUL
Practice Address - State:MN
Practice Address - Zip Code:55130-5302
Practice Address - Country:US
Practice Address - Phone:651-254-7980
Practice Address - Fax:651-254-7969
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2015-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN51674208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program