Provider Demographics
NPI:1760425128
Name:LARSEN, JOHN BRENT
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:BRENT
Last Name:LARSEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 SUNCOAST DR
Mailing Address - Street 2:
Mailing Address - City:MCCOOK LAKE
Mailing Address - State:SD
Mailing Address - Zip Code:57049-4016
Mailing Address - Country:US
Mailing Address - Phone:605-232-9051
Mailing Address - Fax:
Practice Address - Street 1:600 N SIOUX POINT RD
Practice Address - Street 2:
Practice Address - City:DAKOTA DUNES
Practice Address - State:SD
Practice Address - Zip Code:57049-5000
Practice Address - Country:US
Practice Address - Phone:605-232-3332
Practice Address - Fax:605-232-0854
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDR022281367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD100201Medicare PIN
R04414Medicare UPIN