Basic Information
| Provider Information | |||||||||
| NPI: | 1598730152 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | CARSON | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8100 34TH AVE S | ||||||||
| Address2: | MC21110Q | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554251672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9528837172 | ||||||||
| FaxNumber: | 9528835395 | ||||||||
| Practice Location | |||||||||
| Address1: | 8040 OLD CEDAR AVE S STE 100 | ||||||||
| Address2: | |||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554251205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512543456 | ||||||||
| FaxNumber: | 6512545216 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/17/2006 | ||||||||
| LastUpdateDate: | 06/11/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 31091 | MN | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 2083A0300X | 31091 | MN | Y |
ID Information
| ID | Type | State | Issuer | Description | 53585100 | 05 | MN | MEDICAID |