Basic Information
| Provider Information | |||||||||
| NPI: | 1659349934 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | JANET | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | PSYNP, PHD, FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 BUNKER HILL DR | ||||||||
| Address2: | |||||||||
| City: | AITKIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564311865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2189272157 | ||||||||
| FaxNumber: | 2189274130 | ||||||||
| Practice Location | |||||||||
| Address1: | 200 BUNKER HILL DR | ||||||||
| Address2: | |||||||||
| City: | AITKIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564311865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187684011 | ||||||||
| FaxNumber: | 2187684814 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 09/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R133861-6 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | R133861-6 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 500001766 | 01 | MN | MEDICARE WPS - AITKIN CLI | OTHER | 500001767 | 01 | MN | MEDICARE WPS - HOSPITAL | OTHER | 1659349934 | 05 | MN | MEDICAID | 500001764 | 01 | MN | MEDICARE WPS - MCGREGOR | OTHER | 632607200 | 05 | MN | MEDICAID | 500003868 | 01 | MN | MEDICARE WPS | OTHER |