Provider Demographics
NPI:1730142142
Name:LARSON, KRISTIN MICHELLE (PAC)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:MICHELLE
Last Name:LARSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:12450 WAYZATA BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:MINNETONKA
Mailing Address - State:MN
Mailing Address - Zip Code:55305-1927
Mailing Address - Country:US
Mailing Address - Phone:952-546-6866
Mailing Address - Fax:952-512-0038
Practice Address - Street 1:12450 WAYZATA BLVD STE 215
Practice Address - Street 2:
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1927
Practice Address - Country:US
Practice Address - Phone:952-546-6866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN9474363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant