Provider Demographics
NPI:1841608130
Name:LARSON, ROBERT
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:LARSON
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 1:6592 49TH ST N
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:MN
Mailing Address - Zip Code:55128-2001
Mailing Address - Country:US
Mailing Address - Phone:651-770-0098
Mailing Address - Fax:
Practice Address - Street 1:6592 49TH ST N
Practice Address - Street 2:
Practice Address - City:OAKDALE
Practice Address - State:MN
Practice Address - Zip Code:55128-2001
Practice Address - Country:US
Practice Address - Phone:763-780-0075
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-30
Last Update Date:2014-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN365777172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker