Provider Demographics
NPI:1851421036
Name:SAMPSON, LARRY EUGENE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:LARRY
Middle Name:EUGENE
Last Name:SAMPSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2208 10TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-5805
Mailing Address - Country:US
Mailing Address - Phone:320-259-5372
Mailing Address - Fax:
Practice Address - Street 1:1526 NORTHWAY DR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1255
Practice Address - Country:US
Practice Address - Phone:320-251-8385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN023338367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered