Basic Information
| Provider Information | |||||||||
| NPI: | 1639221211 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON-HARGRAFEN | ||||||||
| FirstName: | DABNEY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | LARSON | ||||||||
| OtherFirstName: | DABNEY | ||||||||
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| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | ISU THIELEN STUDENT HEALTH CENTER 2647 UNION DR | ||||||||
| Address2: | |||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 500112029 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152942626 | ||||||||
| FaxNumber: | 5152942794 | ||||||||
| Practice Location | |||||||||
| Address1: | ISU THOMAS B. THIELEN STUDENT HEALTH CENTER | ||||||||
| Address2: | 2647 UNION DRIVE | ||||||||
| City: | AMES | ||||||||
| State: | IA | ||||||||
| PostalCode: | 50011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5152945801 | ||||||||
| FaxNumber: | 5152941190 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2007 | ||||||||
| LastUpdateDate: | 08/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 03061 | IA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 18932 | 05 | IA | MEDICAID | 30585 | 01 | IA | BCBS | OTHER |