Provider Demographics
NPI:1033147251
Name:LARSON, DENISE MARIE (DO)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:MARIE
Last Name:LARSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 HIGHWAY 65 S
Mailing Address - Street 2:FIRSTLIGHT HEALTH SYSTEM
Mailing Address - City:MORA
Mailing Address - State:MN
Mailing Address - Zip Code:55051-1899
Mailing Address - Country:US
Mailing Address - Phone:320-225-3432
Mailing Address - Fax:
Practice Address - Street 1:301 HIGHWAY 65 S
Practice Address - Street 2:FIRSTLIGHT HEALTH SYSTEM
Practice Address - City:MORA
Practice Address - State:MN
Practice Address - Zip Code:55051-1899
Practice Address - Country:US
Practice Address - Phone:320-225-3432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN36489207PE0004X, 207PE0005X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Yes207PE0005XAllopathic & Osteopathic PhysiciansEmergency MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN302513600Medicaid
MN302513600Medicaid
ILL88788Medicare ID - Type Unspecified
E25661Medicare UPIN