Provider Demographics
NPI:1477531150
Name:LARSEN, KRISTINE M (PAC)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:M
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3800 HIGHLAND AVE STE 105
Mailing Address - Street 2:
Mailing Address - City:DOWNERS GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60515-1558
Mailing Address - Country:US
Mailing Address - Phone:630-574-8222
Mailing Address - Fax:630-574-8225
Practice Address - Street 1:3800 HIGHLAND AVE STE 105
Practice Address - Street 2:
Practice Address - City:DOWNERS GROVE
Practice Address - State:IL
Practice Address - Zip Code:60515-1558
Practice Address - Country:US
Practice Address - Phone:630-574-8222
Practice Address - Fax:630-574-8225
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.000355207Y00000X, 363A00000X
IL085000355363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK21616Medicare PIN
ILP21202Medicare UPIN
IL501100Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
ILK21617Medicare PIN