Provider Demographics
NPI:1417113648
Name:LARSON, MATTHEW J
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:J
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 1:2112 HOFFMAN RD
Mailing Address - Street 2:
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56001-5829
Mailing Address - Country:US
Mailing Address - Phone:507-351-9111
Mailing Address - Fax:
Practice Address - Street 1:2112 HOFFMAN RD
Practice Address - Street 2:
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56001-5829
Practice Address - Country:US
Practice Address - Phone:507-351-9111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-07
Last Update Date:2008-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver