Healthcare Provider Details

I. General information

NPI: 1417686833
Provider Name (Legal Business Name): MADELINE ROSE LARSEN PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2022
Last Update Date: 08/02/2022
Certification Date: 08/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9650 GROSS POINT RD STE 2900
SKOKIE IL
60076-5006
US

IV. Provider business mailing address

9650 GROSS POINT RD STE 2900
SKOKIE IL
60076-5006
US

V. Phone/Fax

Practice location:
  • Phone: 847-866-7846
  • Fax: 846-954-5787
Mailing address:
  • Phone: 847-866-7846
  • Fax: 846-954-5787

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number085009052
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: