Provider Demographics
NPI:1164725511
Name:LARSON, ERIC THOMAS (CRNA)
Entity Type:Individual
Prefix:MR
First Name:ERIC
Middle Name:THOMAS
Last Name:LARSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3272 OAK VIEW DR
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-9370
Mailing Address - Country:US
Mailing Address - Phone:651-528-9928
Mailing Address - Fax:
Practice Address - Street 1:3272 OAK VIEW DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55129-9370
Practice Address - Country:US
Practice Address - Phone:651-528-9928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-07
Last Update Date:2014-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR174225-7163W00000X
MNCCNA0086627367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered