Healthcare Provider Details

I. General information

NPI: 1285970624
Provider Name (Legal Business Name): INGRID ANNA LARSON RD, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2012
Last Update Date: 10/09/2026
Certification Date: 10/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 W BARAGA AVE
MARQUETTE MI
49855-4550
US

IV. Provider business mailing address

850 W BARAGA AVE
MARQUETTE MI
49855-4550
US

V. Phone/Fax

Practice location:
  • Phone: 906-360-3606
  • Fax:
Mailing address:
  • Phone: 906-449-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1065603
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: