Provider Demographics
NPI:1982690145
Name:LARSON, SHELLY LYNN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:LYNN
Last Name:LARSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:SHELLY
Other - Middle Name:LYNN
Other - Last Name:BERGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4480 CENTERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55127-3674
Mailing Address - Country:US
Mailing Address - Phone:651-484-2724
Mailing Address - Fax:651-484-2723
Practice Address - Street 1:4480 CENTERVILLE RD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55127-3674
Practice Address - Country:US
Practice Address - Phone:651-484-2724
Practice Address - Fax:651-484-2723
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2012-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9815363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q02646Medicare UPIN