Provider Demographics
NPI:1982630828
Name:LARSON, TIMOTHY L (PA-C)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
Last Name:LARSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 NWAKAMA ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-5529
Mailing Address - Country:US
Mailing Address - Phone:507-929-7696
Mailing Address - Fax:507-393-7697
Practice Address - Street 1:1401 NWAKAMA ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-5529
Practice Address - Country:US
Practice Address - Phone:507-929-7696
Practice Address - Fax:507-393-7697
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0386363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD6826122Medicaid
SDS55778Medicare UPIN
SDS40727Medicare PIN
SD970026824Medicare PIN