Provider Demographics
NPI:1700853397
Name:LARSON, ANDREW W (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:W
Last Name:LARSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13980 NORTHDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-2147
Mailing Address - Country:US
Mailing Address - Phone:763-428-1920
Mailing Address - Fax:763-428-3162
Practice Address - Street 1:13980 NORTHDALE BLVD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-2147
Practice Address - Country:US
Practice Address - Phone:763-428-1920
Practice Address - Fax:763-428-3162
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2011-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN41197208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN165517500Medicaid
MNG84262Medicare UPIN