Provider Demographics
NPI:1285668723
Name:LARSON, CHRISTINE ELIZABETH (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ELIZABETH
Last Name:LARSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:ELIZABETH
Other - Last Name:NEWSWANDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6830 VILLAGREEN VW
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5639
Mailing Address - Country:US
Mailing Address - Phone:815-282-1339
Mailing Address - Fax:815-282-1298
Practice Address - Street 1:6830 VILLAGREEN VW
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5639
Practice Address - Country:US
Practice Address - Phone:815-282-1339
Practice Address - Fax:815-282-1298
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCC5050Medicare ID - Type UnspecifiedRR MEDICARE GROUP #
ILK12990Medicare ID - Type Unspecified
IL210533Medicare ID - Type UnspecifiedMEDICARE GROUP #
IL846930Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILP00020824Medicare ID - Type UnspecifiedRR INDIVIDUAL #
ILP16797Medicare UPIN