Provider Demographics
NPI:1952755506
Name:CARLSON, ASHLEY
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:
Last Name:CARLSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2125 GRANITE DR
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-2978
Mailing Address - Country:US
Mailing Address - Phone:952-693-8203
Mailing Address - Fax:
Practice Address - Street 1:2125 GRANITE DR
Practice Address - Street 2:
Practice Address - City:SHAKOPEE
Practice Address - State:MN
Practice Address - Zip Code:55379-2978
Practice Address - Country:US
Practice Address - Phone:952-693-8203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-20
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN390200000X
MN2255A2300X246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other