Provider Demographics
NPI:1417299124
Name:LARSEN, PATRICIA ANN (RN)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:LARSEN
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 VERNON AVE
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53716-1227
Mailing Address - Country:US
Mailing Address - Phone:608-242-5650
Mailing Address - Fax:
Practice Address - Street 1:1133 VERNON AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53716-1227
Practice Address - Country:US
Practice Address - Phone:608-242-5650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI157948-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3443219438Medicaid