Provider Demographics
NPI:1396184123
Name:CARSON, KATHERINE MARIE (NP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:MARIE
Last Name:CARSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5074
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57117-5074
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3035 DEMERS AVE
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4040
Practice Address - Country:US
Practice Address - Phone:701-746-7521
Practice Address - Fax:701-795-2553
Is Sole Proprietor?:No
Enumeration Date:2013-06-14
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN796363L00000X
NDR32234363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND11344Medicaid
ND11344Medicaid