Provider Demographics
NPI:1588689947
Name:CARLSON, TRENT PATRICK (MD)
Entity type:Individual
Prefix:
First Name:TRENT
Middle Name:PATRICK
Last Name:CARLSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 RIDGEWAY RD
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-2153
Mailing Address - Country:US
Mailing Address - Phone:507-537-9007
Mailing Address - Fax:
Practice Address - Street 1:1409 RIDGEWAY RD
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-2153
Practice Address - Country:US
Practice Address - Phone:612-385-7105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32114208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN072390800Medicaid
D81282Medicare UPIN
MN072390800Medicaid