Healthcare Provider Details

I. General information

NPI: 1417945940
Provider Name (Legal Business Name): LISA CAROL LARSON PAC
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: LISA CAROL GRANSTROM PAC

II. Dates (important events)

Enumeration Date: 10/10/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

822 YELLOW BRICK RD
CHASKA MN
55318-2152
US

IV. Provider business mailing address

822 YELLOW BRICK RD
CHASKA MN
55318-2152
US

V. Phone/Fax

Practice location:
  • Phone: 952-448-3303
  • Fax: 952-448-4409
Mailing address:
  • Phone: 952-448-3303
  • Fax: 952-448-4409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9622
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: