Basic Information
| Provider Information | |||||||||
| NPI: | 1366822587 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | ELIZABETH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8170 33RD AVE | ||||||||
| Address2: | MS 21110Q | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554254516 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515522600 | ||||||||
| FaxNumber: | 6515522614 | ||||||||
| Practice Location | |||||||||
| Address1: | 5625 CENEX DR | ||||||||
| Address2: | |||||||||
| City: | INVER GROVE HEIGHTS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 55077 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6515522600 | ||||||||
| FaxNumber: | 6515522614 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2015 | ||||||||
| LastUpdateDate: | 04/20/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 2022008365 | MO | N | Allopathic & Osteopathic Physicians | Family Medicine | 208D00000X | 60805 | MN | N | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | 60805 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.