Provider Demographics
NPI:1962489914
Name:LARSON, KELLIE D (PA-C)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:D
Last Name:LARSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:SYMONSBERGEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8201 NORTHWOODS DR
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68505-3092
Mailing Address - Country:US
Mailing Address - Phone:402-465-5600
Mailing Address - Fax:402-327-6074
Practice Address - Street 1:8201 NORTHWOODS DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68505-3092
Practice Address - Country:US
Practice Address - Phone:402-465-5600
Practice Address - Fax:402-327-6017
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2017-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE737363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025151600Medicaid
NE47079049100Medicaid
NE10026368300Medicaid
NE47079049112Medicaid