Provider Demographics
NPI:1417945940
Name:LARSON, LISA CAROL (PAC)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:CAROL
Last Name:LARSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:CAROL
Other - Last Name:GRANSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:822 YELLOW BRICK RD
Mailing Address - Street 2:
Mailing Address - City:CHASKA
Mailing Address - State:MN
Mailing Address - Zip Code:55318-2152
Mailing Address - Country:US
Mailing Address - Phone:952-448-3303
Mailing Address - Fax:952-448-4409
Practice Address - Street 1:822 YELLOW BRICK RD
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-2152
Practice Address - Country:US
Practice Address - Phone:952-448-3303
Practice Address - Fax:952-448-4409
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9622363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN414338800Medicaid
P62104Medicare UPIN
MN414338800Medicaid