Healthcare Provider Details

I. General information

NPI: 1508610072
Provider Name (Legal Business Name): ZACHARY CARLSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2024
Last Update Date: 12/10/2025
Certification Date: 12/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 PARK AVE
MINNEAPOLIS MN
55415-1623
US

IV. Provider business mailing address

715 S 8TH ST
MINNEAPOLIS MN
55404-7530
US

V. Phone/Fax

Practice location:
  • Phone: 612-873-5450
  • Fax:
Mailing address:
  • Phone: 612-873-5450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14973
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number14973
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: