Healthcare Provider Details

I. General information

NPI: 1275697534
Provider Name (Legal Business Name): DON A LARSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 03/13/2020
Certification Date: 03/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 S RANDALL RD
ALGONQUIN IL
60102-5944
US

IV. Provider business mailing address

BOX 78534
MILWAUKEE WI
53278-8534
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-9491
  • Fax: 815-381-7498
Mailing address:
  • Phone: 815-398-9491
  • Fax: 815-381-7498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1072529
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-002924
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: