Basic Information
Provider Information | |||||||||
NPI: | 1043576853 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LARSON | ||||||||
FirstName: | KATIE | ||||||||
MiddleName: | ELIZABETH | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 77 N HARMON DR | ||||||||
Address2: |   | ||||||||
City: | MITCHELL | ||||||||
State: | SD | ||||||||
PostalCode: | 573016242 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6056709305 | ||||||||
FaxNumber: | 6059963385 | ||||||||
Practice Location | |||||||||
Address1: | 1205 S GRANGE AVE | ||||||||
Address2: | SUITE 307 | ||||||||
City: | SIOUX FALLS | ||||||||
State: | SD | ||||||||
PostalCode: | 571050407 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6053287800 | ||||||||
FaxNumber: | 6053287899 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/05/2012 | ||||||||
LastUpdateDate: | 04/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 0040 | SD | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.