Provider Demographics
NPI:1891761664
Name:LARSON-JOHNSON, TERI LEE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TERI
Middle Name:LEE
Last Name:LARSON-JOHNSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TERI
Other - Middle Name:LEE
Other - Last Name:SIGURDSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-8364
Mailing Address - Fax:
Practice Address - Street 1:420 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-1901
Practice Address - Country:US
Practice Address - Phone:218-786-8364
Practice Address - Fax:320-229-5160
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9190363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R92463Medicare UPIN
MN970000397Medicare ID - Type Unspecified