Provider Demographics
NPI:1518980572
Name:LARSEN, CAROL N (PA)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:N
Last Name:LARSEN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4405 E 26TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57103-4136
Mailing Address - Country:US
Mailing Address - Phone:605-332-2883
Mailing Address - Fax:605-332-9101
Practice Address - Street 1:4405 E 26TH ST
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57103-4136
Practice Address - Country:US
Practice Address - Phone:605-332-2883
Practice Address - Fax:605-332-9101
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDS8382Medicare PIN
SDP00008845Medicare PIN
R02500Medicare UPIN