Healthcare Provider Details

I. General information

NPI: 1821074154
Provider Name (Legal Business Name): LARRY TAFT NELSEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 1ST DR NW
AUSTIN MN
55912-2941
US

IV. Provider business mailing address

1000 1ST DR NW
AUSTIN MN
55912-2941
US

V. Phone/Fax

Practice location:
  • Phone: 507-434-1092
  • Fax: 507-434-1477
Mailing address:
  • Phone: 507-434-1092
  • Fax: 507-434-1477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number20617
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: