Basic Information
| Provider Information | |||||||||
| NPI: | 1538122817 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | JON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8675 VALLEY CREEK RD | ||||||||
| Address2: | |||||||||
| City: | WOODBURY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551252337 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6512413000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1285 NININGER RD | ||||||||
| Address2: | |||||||||
| City: | HASTINGS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550331086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514804200 | ||||||||
| FaxNumber: | 6514804434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2006 | ||||||||
| LastUpdateDate: | 03/23/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 9355 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 040965100 | 05 | MN | MEDICAID | 42990800 | 01 | MN | GROUP HEALTH EAU CLAIRE | OTHER | 01-13610 | 01 | MN | MEDICA | OTHER | 970015689 | 01 | MN | RAILROAD MEDICARE | OTHER | NA9141022759 | 01 | MN | PREFERRED ONE | OTHER | 127666 | 01 | MN | UCARE MINNESOTA | OTHER | 16F30LA | 01 | MN | BLUE CROSS | OTHER | HP30168 | 01 | MN | HEALTH PARTNERS | OTHER | 850267 | 01 | MN | AMERICA'S PPO | OTHER |