Basic Information
| Provider Information | |||||||||
| NPI: | 1871937474 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CARLSON | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | KRISTEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3500 TOWER AVE | ||||||||
| Address2: | |||||||||
| City: | SUPERIOR | ||||||||
| State: | WI | ||||||||
| PostalCode: | 548804491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158177100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 330 N 8TH AVE E | ||||||||
| Address2: | |||||||||
| City: | DULUTH | ||||||||
| State: | MN | ||||||||
| PostalCode: | 558052024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187231112 | ||||||||
| FaxNumber: | 2185299120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2013 | ||||||||
| LastUpdateDate: | 05/24/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 57990 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0001-0117025 | 01 | MEDICA | OTHER | 1871937474 | 01 | MN | BCBS | OTHER | 1871937474 | 05 | MN | MEDICAID |