Provider Demographics
NPI:1477585081
Name:LARSEN, MICHAELA R (PAC)
Entity Type:Individual
Prefix:
First Name:MICHAELA
Middle Name:R
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:MICHAELA
Other - Middle Name:R
Other - Last Name:SCHRAMM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3755
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68103-0755
Mailing Address - Country:US
Mailing Address - Phone:402-354-2100
Mailing Address - Fax:402-354-2155
Practice Address - Street 1:PO BOX 337
Practice Address - Street 2:
Practice Address - City:VALLEY
Practice Address - State:NE
Practice Address - Zip Code:68064-0337
Practice Address - Country:US
Practice Address - Phone:402-359-2277
Practice Address - Fax:402-359-5432
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1068363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE47068731734Medicaid
470834610OtherTAX IDENIFICATION NUMBER
NE47068731741Medicaid
IA1477585081Medicaid
NE47068731749Medicaid
NE10026480100Medicaid
NE47068731761Medicaid
NE47068731761Medicaid