Basic Information
Provider Information | |||||||||
NPI: | 1740267848 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NIELSON | ||||||||
FirstName: | LARS | ||||||||
MiddleName: | ERLING | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 173 MIDDLE ST | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | NH | ||||||||
PostalCode: | 035843508 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037885029 | ||||||||
FaxNumber: | 6037885607 | ||||||||
Practice Location | |||||||||
Address1: | 170 MIDDLE ST | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | NH | ||||||||
PostalCode: | 035843556 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6037882521 | ||||||||
FaxNumber: | 6037885027 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/29/2005 | ||||||||
LastUpdateDate: | 04/17/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X |   |   | N |   | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 207V00000X | 8303 | NH | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 30203801 | 05 | NH |   | MEDICAID | 0001017 | 05 | VT |   | MEDICAID |