Provider Demographics
NPI:1003128059
Name:LARSEN, DOUGLAS STEVEN (PA-C)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:STEVEN
Last Name:LARSEN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 HEWITT BLVD
Mailing Address - Street 2:
Mailing Address - City:RED WING
Mailing Address - State:MN
Mailing Address - Zip Code:55066-2848
Mailing Address - Country:US
Mailing Address - Phone:651-267-5000
Mailing Address - Fax:
Practice Address - Street 1:701 HEWITT BLVD
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066
Practice Address - Country:US
Practice Address - Phone:651-267-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-07
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
WI3095363AM0700X
MN12317363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical