Provider Demographics
NPI:1568465201
Name:LARSON, STEPHEN (CRNA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:LARSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1752 EDGEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:MN
Mailing Address - Zip Code:55987-2149
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:112 E 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANTIGO
Practice Address - State:WI
Practice Address - Zip Code:54409-2710
Practice Address - Country:US
Practice Address - Phone:715-623-2331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-26
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-081276-4367500000X
WI202157-30367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
1882OtherIBAX
MN136542800Medicaid
52D0662095OtherCLIA
WI43293000Medicaid
WI43293000Medicaid