Basic Information
| Provider Information | |||||||||
| NPI: | 1689650368 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LARSON | ||||||||
| FirstName: | LARRY | ||||||||
| MiddleName: | W | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1015 MARSH ST | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560015294 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073894700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1025 MARSH ST | ||||||||
| Address2: | |||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560014752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076254031 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 47033 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
No ID Information.