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: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 LONG LAKE RD STE 150
NEW BRIGHTON MN
55112-6414
US

IV. Provider business mailing address

900 LONG LAKE RD STE 150
NEW BRIGHTON MN
55112-6414
US

V. Phone/Fax

Practice location:
  • Phone: 612-213-2370
  • Fax: 612-524-5571
Mailing address:
  • Phone: 612-213-2370
  • Fax: 612-524-5571

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: