Provider Demographics
NPI:1841459658
Name:LARSON, MAGNOLIA JEAN (DO)
Entity type:Individual
Prefix:DR
First Name:MAGNOLIA
Middle Name:JEAN
Last Name:LARSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MAGNOLIA
Other - Middle Name:JEAN
Other - Last Name:WINSOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:100 N NINE MOUND RD
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:WI
Practice Address - Zip Code:53593-1032
Practice Address - Country:US
Practice Address - Phone:608-845-9531
Practice Address - Fax:608-845-5954
Is Sole Proprietor?:No
Enumeration Date:2008-06-06
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60918207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN080017049Medicare Oscar/Certification
MN080017051Medicare Oscar/Certification
MN080017053Medicare Oscar/Certification
MN080017050Medicare Oscar/Certification
MN080017054Medicare Oscar/Certification