Provider Demographics
NPI:1265470371
Name:LARSON, BRUCE D (PAC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:D
Last Name:LARSON
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:701-683-4134
Mailing Address - Fax:701-683-4094
Practice Address - Street 1:819 MAIN ST
Practice Address - Street 2:
Practice Address - City:LISBON
Practice Address - State:ND
Practice Address - Zip Code:58054-4244
Practice Address - Country:US
Practice Address - Phone:701-683-4134
Practice Address - Fax:701-683-4094
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0257363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND137047OtherUCARE #
ND1797235OtherAMERICA'S PPO/ARAZ #
NDDA9061031057OtherPREFERRED ONE #
ND0113759OtherMEDICA #
ND0113760OtherMEDICA #
ND23227OtherNDBS #
ND514S4LSOtherMNBS #
ND798727700Medicaid
NDHP38590OtherHEALTHPARTNERS #
ND514S3LAOtherMNBS #
ND515S5LAOtherMNBS #
ND0113761OtherMEDICA #
ND23228OtherNDBS #
NDP00055624OtherRR MEDICARE #
ND23228Medicare ID - Type UnspecifiedND MEDICARE #
ND0113759OtherMEDICA #
NDDA9061031057OtherPREFERRED ONE #
ND514S4LSOtherMNBS #