Provider Demographics
NPI:1992238604
Name:CARLSON, RYAN (MD)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
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 1:3366 OAKDALE AVE N STE 315
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55422-2967
Mailing Address - Country:US
Mailing Address - Phone:763-581-5372
Mailing Address - Fax:
Practice Address - Street 1:3366 OAKDALE AVE N STE 315
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2967
Practice Address - Country:US
Practice Address - Phone:763-581-5372
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-10
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN644192084P0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry