Basic Information
| Provider Information | |||||||||
| NPI: | 1154315133 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | KATHERINE | ||||||||
| MiddleName: | MCCOURT ROBINSON | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 SPRINGER DR | ||||||||
| Address2: | |||||||||
| City: | LOMBARD | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601486413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8157448554 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4725 36TH AVE N | ||||||||
| Address2: | |||||||||
| City: | CRYSTAL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554222169 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2182082058 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2005 | ||||||||
| LastUpdateDate: | 01/25/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9624 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 131240 | 01 | UCARE | OTHER | 215598200 | 05 | MN | MEDICAID | 0115028 | 01 | MEDICA | OTHER |