Provider Demographics
NPI:1457982753
Name:LARSON, CONNOR CHARLES
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:CHARLES
Last Name:LARSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5492 LAMBERT AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBERTVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55301-9720
Mailing Address - Country:US
Mailing Address - Phone:763-360-3215
Mailing Address - Fax:
Practice Address - Street 1:5492 LAMBERT AVE NE
Practice Address - Street 2:
Practice Address - City:ALBERTVILLE
Practice Address - State:MN
Practice Address - Zip Code:55301-9720
Practice Address - Country:US
Practice Address - Phone:763-360-3215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer