Provider Demographics
NPI:1255683777
Name:LARSON, NATHAN S (CRNA)
Entity Type:Individual
Prefix:MR
First Name:NATHAN
Middle Name:S
Last Name:LARSON
Suffix:
Gender:M
Credentials:CRNA
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Mailing Address - Street 1:PO BOX 505164
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5164
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:100 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9210
Practice Address - Country:US
Practice Address - Phone:417-533-6100
Practice Address - Fax:417-533-6021
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2015-07-16
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO2013002285367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO600420082Medicaid
MO1255683777Medicaid
MO600420082Medicaid
MO600420082Medicaid