Basic Information
| Provider Information | |||||||||
| NPI: | 1003128059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | STEVEN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 701 HEWITT BLVD | ||||||||
| Address2: | |||||||||
| City: | RED WING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550662848 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512675000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 701 HEWITT BLVD | ||||||||
| Address2: | |||||||||
| City: | RED WING | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55066 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512675000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2010 | ||||||||
| LastUpdateDate: | 10/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 3095 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 12317 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.