Provider Demographics
NPI:1821377805
Name:LARSON, KAITLIN MICHELE (PAC)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MICHELE
Last Name:LARSON
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:KAITLIN
Other - Middle Name:MICHELE
Other - Last Name:GADDIE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PAC
Mailing Address - Street 1:1012 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2200
Mailing Address - Country:US
Mailing Address - Phone:218-249-2450
Mailing Address - Fax:218-249-2451
Practice Address - Street 1:1012 E 2ND ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2200
Practice Address - Country:US
Practice Address - Phone:218-249-2450
Practice Address - Fax:218-249-2451
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN10964363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN10964OtherMN LICENSE