Provider Demographics
NPI:1851353320
Name:LARSON, KEITH WILLIAM (CRNA)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:WILLIAM
Last Name:LARSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
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Mailing Address - Street 1:1529 IVORY CT
Mailing Address - Street 2:
Mailing Address - City:LAKE ELMO
Mailing Address - State:MN
Mailing Address - Zip Code:55042-9311
Mailing Address - Country:US
Mailing Address - Phone:651-646-3091
Mailing Address - Fax:651-646-3124
Practice Address - Street 1:3300 OAKDALE AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2926
Practice Address - Country:US
Practice Address - Phone:763-581-3980
Practice Address - Fax:763-581-3591
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2019-06-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN1049989367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered