Provider Demographics
NPI:1295138931
Name:CARLSON, BRITTA LEE (PAC)
Entity type:Individual
Prefix:
First Name:BRITTA
Middle Name:LEE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:BRITTA
Other - Middle Name:LEE
Other - Last Name:PETERSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2355 HWY 36 W. STE. 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-292-2000
Mailing Address - Fax:
Practice Address - Street 1:2355 HWY 36 W.
Practice Address - Street 2:STE. 100
Practice Address - City:ROSEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55113
Practice Address - Country:US
Practice Address - Phone:651-292-2000
Practice Address - Fax:651-439-0232
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3455-23363AS0400X
MN11629363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical