Provider Demographics
NPI:1447482823
Name:CARLSON, MARLA ELLEN (PA-C)
Entity type:Individual
Prefix:MRS
First Name:MARLA
Middle Name:ELLEN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MARLA
Other - Middle Name:ELLEN
Other - Last Name:MCCONKEY (MAIDEN)
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:855 MANKATO AVE
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987
Mailing Address - Country:US
Mailing Address - Phone:507-457-4328
Mailing Address - Fax:507-474-3225
Practice Address - Street 1:855 MANKATO AVE
Practice Address - Street 2:
Practice Address - City:WINONA
Practice Address - State:MN
Practice Address - Zip Code:55987
Practice Address - Country:US
Practice Address - Phone:507-457-4328
Practice Address - Fax:507-474-3225
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2021-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN390200000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program