Healthcare Provider Details

I. General information

NPI: 1629700968
Provider Name (Legal Business Name): MADELINE GRACE CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2022
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10705 TOWN SQUARE DR NE STE 210
BLAINE MN
55449-8187
US

IV. Provider business mailing address

PO BOX 734240
CHICAGO IL
60673-4244
US

V. Phone/Fax

Practice location:
  • Phone: 763-284-2992
  • Fax: 763-427-8131
Mailing address:
  • Phone: 629-519-6543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: