Provider Demographics
NPI:1023052073
Name:LARSON, KIRSTEN W (MD)
Entity type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:W
Last Name:LARSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3329 N RICHMOND STREET
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911
Mailing Address - Country:US
Mailing Address - Phone:920-380-2715
Mailing Address - Fax:
Practice Address - Street 1:3329 N RICHMOND STREET
Practice Address - Street 2:
Practice Address - City:APPLETON
Practice Address - State:WI
Practice Address - Zip Code:54911
Practice Address - Country:US
Practice Address - Phone:920-380-2715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI41362-020207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32643000Medicaid
WI32643000Medicaid
WI052645300Medicare PIN
WI053371018Medicare PIN