Provider Demographics
NPI:1871937474
Name:CARLSON, AMANDA KRISTEN (MD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:KRISTEN
Last Name:CARLSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 TOWER AVE
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:WI
Mailing Address - Zip Code:54880-4491
Mailing Address - Country:US
Mailing Address - Phone:715-817-7100
Mailing Address - Fax:
Practice Address - Street 1:330 N 8TH AVE E
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2024
Practice Address - Country:US
Practice Address - Phone:218-723-1112
Practice Address - Fax:218-529-9120
Is Sole Proprietor?:No
Enumeration Date:2013-04-25
Last Update Date:2016-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN57990207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
0001-0117025OtherMEDICA
MN1871937474OtherBCBS
MN1871937474Medicaid