Provider Demographics
NPI:1033606595
Name:LARSON, DANIEL JAMES
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JAMES
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4701 1ST AVE S
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55803-1308
Mailing Address - Country:US
Mailing Address - Phone:218-349-8506
Mailing Address - Fax:
Practice Address - Street 1:4701 1ST AVE S
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55803-1308
Practice Address - Country:US
Practice Address - Phone:218-349-8506
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program