Basic Information
| Provider Information | |||||||||
| NPI: | 1770542466 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSEN | ||||||||
| FirstName: | LAUREL | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | FRY | ||||||||
| OtherFirstName: | LAUREL | ||||||||
| OtherMiddleName: | JEAN | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 43 | ||||||||
| Address2: | MR 10809 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554400043 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6122624813 | ||||||||
| FaxNumber: | 6122624194 | ||||||||
| Practice Location | |||||||||
| Address1: | 920 E 28TH ST | ||||||||
| Address2: | SUITE 190 | ||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554071139 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6128631893 | ||||||||
| FaxNumber: | 6128633809 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35284 | MN | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.