Provider Demographics
NPI:1760048946
Name:CARLSON, AMITY ALICE (PA-C)
Entity Type:Individual
Prefix:
First Name:AMITY
Middle Name:ALICE
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 1:1600 UNIVERSITY AVE W STE 205
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-3825
Mailing Address - Country:US
Mailing Address - Phone:651-955-6255
Mailing Address - Fax:
Practice Address - Street 1:1600 UNIVERSITY AVE W STE 205
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-3825
Practice Address - Country:US
Practice Address - Phone:651-955-6255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-14
Last Update Date:2020-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN13021363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant