Provider Demographics
NPI:1508610072
Name:CARLSON, ZACHARY (PA-C)
Entity type:Individual
Prefix:
First Name:ZACHARY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:M
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 1:8314 170TH AVE
Mailing Address - Street 2:
Mailing Address - City:ROYALTON
Mailing Address - State:MN
Mailing Address - Zip Code:56373-3915
Mailing Address - Country:US
Mailing Address - Phone:320-630-0397
Mailing Address - Fax:
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:320-630-0397
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-12
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN14973363A00000X, 208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208800000XAllopathic & Osteopathic PhysiciansUrology